Podcast
Questions and Answers
What should be documented regarding the application of Montgomery straps?
What should be documented regarding the application of Montgomery straps?
- The time it takes to apply the dressings
- Only the patient's name and medical record number
- The types of medications administered while dressing
- The patient's response to dressing care and pain assessment (correct)
Which of the following is NOT a consideration when moving a patient up in bed?
Which of the following is NOT a consideration when moving a patient up in bed?
- The patient's body weight
- The patient’s ability to understand directions
- Any activity restrictions for the patient
- The nutritional needs of the patient (correct)
What action should be taken if a caregiver needs to lift more than 35 pounds of a patient's weight?
What action should be taken if a caregiver needs to lift more than 35 pounds of a patient's weight?
- Seek assistance from a colleague
- Use only a friction-reducing sheet for lifting
- Lift without the need for further assistance
- Consider the patient fully dependent and use assistive devices (correct)
Which method is suggested to avoid injury while moving a patient in bed?
Which method is suggested to avoid injury while moving a patient in bed?
In the context of delegation, who can be assigned to move a patient up in bed?
In the context of delegation, who can be assigned to move a patient up in bed?
Why is it important to document the wound description and drainage after applying dressing?
Why is it important to document the wound description and drainage after applying dressing?
What should be included in patient and family education regarding dressing care?
What should be included in patient and family education regarding dressing care?
How should documentation be approached after applying dressings to a wound?
How should documentation be approached after applying dressings to a wound?
What is the primary purpose of patient identification?
What is the primary purpose of patient identification?
What is the benefit of using proper bed height during patient procedures?
What is the benefit of using proper bed height during patient procedures?
What should be assessed to determine the need for additional caregivers during patient movement?
What should be assessed to determine the need for additional caregivers during patient movement?
In what position should the bed be adjusted if the patient can tolerate it?
In what position should the bed be adjusted if the patient can tolerate it?
Which piece of equipment is specifically mentioned as necessary for assisting with patient mobility?
Which piece of equipment is specifically mentioned as necessary for assisting with patient mobility?
Why is it recommended to remove pillows from under the patient except for one at the head?
Why is it recommended to remove pillows from under the patient except for one at the head?
What is the primary goal of the nursing diagnosis during assessment?
What is the primary goal of the nursing diagnosis during assessment?
What is the role of positioning nurses on either side of the bed?
What is the role of positioning nurses on either side of the bed?
What is the purpose of a friction-reducing sheet under the patient?
What is the purpose of a friction-reducing sheet under the patient?
When should PPE be utilized according to the nursing protocols outlined?
When should PPE be utilized according to the nursing protocols outlined?
Which outcome is NOT included in the outcome identification and planning for patient movement?
Which outcome is NOT included in the outcome identification and planning for patient movement?
How can a patient assist with their own movement during a procedure?
How can a patient assist with their own movement during a procedure?
What is a consequence of not positioning the patient's legs correctly?
What is a consequence of not positioning the patient's legs correctly?
Why is it important to assess for tubes and IV lines before moving a patient?
Why is it important to assess for tubes and IV lines before moving a patient?
Which of the following factors does NOT need to be considered when determining patient mobility needs?
Which of the following factors does NOT need to be considered when determining patient mobility needs?
What is the rationale for performing hand hygiene before patient handling?
What is the rationale for performing hand hygiene before patient handling?
What is the primary purpose of having the patient fold their arms across their chest during repositioning?
What is the primary purpose of having the patient fold their arms across their chest during repositioning?
Why is it important for nurses to position themselves at the patient's midsection with feet shoulder-width apart?
Why is it important for nurses to position themselves at the patient's midsection with feet shoulder-width apart?
What effect does engaging the bed mechanism have when repositioning a patient?
What effect does engaging the bed mechanism have when repositioning a patient?
Which technique helps prevent back injury during the patient transfer?
Which technique helps prevent back injury during the patient transfer?
How does the patient assisting in the move benefit the nurses?
How does the patient assisting in the move benefit the nurses?
What is the purpose of readjusting the bed to a normal height after repositioning a patient?
What is the purpose of readjusting the bed to a normal height after repositioning a patient?
What does the rocking motion utilized during patient transfer achieve?
What does the rocking motion utilized during patient transfer achieve?
What is the benefit of having essential items and the call bell within the patient's reach after repositioning?
What is the benefit of having essential items and the call bell within the patient's reach after repositioning?
Study Notes
Documentation Guidelines
- Wound care: Document the wound appearance, drainage, and surrounding skin condition before and after applying Montgomery straps
- Dressing details: Record dressing type used, including skin protectant and barrier
- Patient response: Document the pain level and patient's response to dressing care
- Patient education: Include any relevant educational information for the patient and family
Safe Patient Handling
- Use friction-reducing sheet for movement to minimize shearing force during repositioning
- Delegate task to qualified staff, taking into account the patient's condition and needs
- Consult Safe Patient Handling Algorithm in Skill 173
Moving Patient Up in Bed Procedure Steps
- Assessment: Review medical record, patient's condition, mobility limitations, ability to understand directions, and weight
- Hand hygiene: Perform hand hygiene and don PPE before handling patient
- Patient identification: Verify patient's identity
- Privacy: Close curtains and door
- Bed position:
- Set bed at comfortable height
- Adjust head of the bed to flat position or as low as tolerated by patient
- Place in slight Trendelenburg position if feasible
- Pillows: Remove all pillows except one at the head of the bed
- Positioning: Have one nurse on each side of the bed, both side rails down
- Friction-reducing sheet: Use if not already in place
- Patient assistance: Encourage patient (if able) to bend legs, flatten feet, fold arms across chest, assist with lifting head
- Nurse positioning: Position nurses on either side of the patient's midsection, feet spread shoulder width apart
- Rocking motion: Nurses grasp sheet securely, flex their knees, tighten abdominal and gluteal muscles while keeping back straight, rock back and forth then move patient on the count of three
- Post-procedure care: Assist patient to a comfortable position, adjust pillows, return bed to normal setting, raise side rails as needed, lower bed to lowest position
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Description
This quiz focuses on the essential aspects of nursing documentation, particularly in wound care and patient education. It also outlines safe patient handling techniques and procedures for moving patients in bed. Test your knowledge on these crucial nursing practices to ensure both patient safety and quality care.
