Podcast
Questions and Answers
Which patient population requires careful assessment of bathwater temperature to prevent injury?
Which patient population requires careful assessment of bathwater temperature to prevent injury?
- Patients with cognitive impairments
- Older adults and those with reduced sensation (correct)
- Patients with active infections
- Patients undergoing physical therapy
What is the first step in the procedure for providing a bath to a patient?
What is the first step in the procedure for providing a bath to a patient?
- Identify the patient using two identifiers
- Gather the necessary equipment and supplies
- Ensure the room is warm and comfortable
- Verify the health care provider’s orders (correct)
What should you assess regarding the patient prior to starting the bath?
What should you assess regarding the patient prior to starting the bath?
- The patient's tolerance for bathing and comfort level (correct)
- The patient’s medication history
- The patient’s mobility aids and devices
- The patient’s dietary restrictions
During the bathing procedure, what should be done with soiled linen?
During the bathing procedure, what should be done with soiled linen?
How should you proceed if a patient has an extremity injury while removing their gown?
How should you proceed if a patient has an extremity injury while removing their gown?
What is the primary reason for ensuring that compression stockings are fitted correctly by a nurse?
What is the primary reason for ensuring that compression stockings are fitted correctly by a nurse?
Which of the following is NOT a non-pharmacological pain intervention?
Which of the following is NOT a non-pharmacological pain intervention?
What is the correct method for applying compression stockings?
What is the correct method for applying compression stockings?
What must be done before applying restraints to a patient?
What must be done before applying restraints to a patient?
What is a critical action to take when teaching a spouse to perform slow stroke back massages?
What is a critical action to take when teaching a spouse to perform slow stroke back massages?
Which item is essential to gather before applying restraints?
Which item is essential to gather before applying restraints?
What common misconception might patients have regarding therapeutic touch as a pain intervention?
What common misconception might patients have regarding therapeutic touch as a pain intervention?
Which condition would most likely require using adjuvant analgesics?
Which condition would most likely require using adjuvant analgesics?
What should be avoided when securing restraints to a patient's bed?
What should be avoided when securing restraints to a patient's bed?
What is the recommended method of securing restraints?
What is the recommended method of securing restraints?
What is a critical assessment that should be performed when restraints are used?
What is a critical assessment that should be performed when restraints are used?
What is the primary purpose of nursing diagnosis in the nursing process?
What is the primary purpose of nursing diagnosis in the nursing process?
Which of the following is NOT a step in the nursing process?
Which of the following is NOT a step in the nursing process?
How often should restraints be removed for assessment?
How often should restraints be removed for assessment?
Which position is recommended for a patient with extremity restraints to minimize aspiration risk?
Which position is recommended for a patient with extremity restraints to minimize aspiration risk?
Which intervention is least likely to be effective for a patient experiencing respiratory distress?
Which intervention is least likely to be effective for a patient experiencing respiratory distress?
During the transfer from wheelchair to bed, what is the first step to ensure safety?
During the transfer from wheelchair to bed, what is the first step to ensure safety?
Which device should be secure and within the patient's reach to ensure their safety?
Which device should be secure and within the patient's reach to ensure their safety?
What is the purpose of elevating the head of the bed when assisting a patient in respiratory distress?
What is the purpose of elevating the head of the bed when assisting a patient in respiratory distress?
What is a key consideration when using restraints in relation to medical devices?
What is a key consideration when using restraints in relation to medical devices?
What should be done with used supplies and equipment after restraint application?
What should be done with used supplies and equipment after restraint application?
Which technique is important when positioning a wheelchair for transfer?
Which technique is important when positioning a wheelchair for transfer?
What kind of restraints are many health care organizations now prohibiting due to safety concerns?
What kind of restraints are many health care organizations now prohibiting due to safety concerns?
What is the primary focus of the analysis step in the clinical judgment model?
What is the primary focus of the analysis step in the clinical judgment model?
Which statement reflects a proper practice regarding restraint use?
Which statement reflects a proper practice regarding restraint use?
Which action is performed immediately after adjusting the height of the bed for transfer?
Which action is performed immediately after adjusting the height of the bed for transfer?
What key factor should be assessed to ensure a successful patient transfer from a wheelchair?
What key factor should be assessed to ensure a successful patient transfer from a wheelchair?
What is a critical intervention for a patient with respiratory distress when monitoring vital signs?
What is a critical intervention for a patient with respiratory distress when monitoring vital signs?
What is the primary purpose of goggles in a healthcare setting?
What is the primary purpose of goggles in a healthcare setting?
Which personal protective equipment is NOT considered part of standard PPE?
Which personal protective equipment is NOT considered part of standard PPE?
What is the first step in the process of donning personal protective equipment?
What is the first step in the process of donning personal protective equipment?
When removing PPE, what is the correct method for removing the mask?
When removing PPE, what is the correct method for removing the mask?
In what situations are airborne precautions implemented?
In what situations are airborne precautions implemented?
Which area is especially important to inspect for cleanliness in patients with limited mobility?
Which area is especially important to inspect for cleanliness in patients with limited mobility?
What is the last step performed after removing all personal protective equipment?
What is the last step performed after removing all personal protective equipment?
Which of the following is NOT a characteristic of face shields?
Which of the following is NOT a characteristic of face shields?
What is a common mistake when removing eyewear as part of PPE?
What is a common mistake when removing eyewear as part of PPE?
When cleaning a patient with mobility issues, which issue should be prioritized?
When cleaning a patient with mobility issues, which issue should be prioritized?
Study Notes
Application of Compression Stockings
- Compression stockings may be knee or thigh length; proper fitting is critical.
- Nurses must fit stockings, while application and maintenance can be delegated.
- Measure length (knee: heel to behind the knee; thigh: heel to gluteal fold) and width (at the largest part of calf/thigh).
- To apply, invert the stockings and roll them onto the leg from toe to knee or thigh.
- The fit should be snug yet not painful; stockings too small could restrict blood flow.
Interventions for Pain Management
Non-Pharmacological Interventions
- Techniques include positioning, cutaneous stimulation (cold, hot, touch), acupuncture, acupressure, and TENS therapy.
- Cognitive-behavioral strategies like distraction, relaxation, imagery, and music therapy are beneficial.
- Therapeutic touch involves the nurse using hands near the body for energy balance, particularly useful for patients with cancer or fibromyalgia.
Pharmacological Interventions
- Use opioids (morphine, codeine, fentanyl) for severe pain management.
- Nonopioid analgesics include NSAIDs, acetaminophen, and sucrose for infants.
- Adjuvant analgesics might involve corticosteroids, gabapentin, carbamazepine, antidepressants, and botulinum toxin.
- Encourage patients to follow prescribed medication regimens and select previously effective non-pharmacological methods.
Restraint Application and Management
- Gather equipment and perform hand hygiene; provide privacy and calm introduction to the patient.
- Verify healthcare provider orders and ensure signed consent if necessary.
- Identify patients using two identifiers, such as name and birth date.
- Explain the procedure to the patient; if uncooperative, consult the practitioner.
- Attach restraint straps to the stationary bed frame, avoiding side rails; secure with a quick-release tie.
- Remove restraints at least every two hours; assess skin integrity, pulses, and circulation regularly.
- Document restraint usage, patient response, and any necessary outcomes.
Key Elements of Restraint Use
- Many facilities prohibit jacket restraints due to the risk of injury.
- Restraint use should be limited and based on thorough patient assessment.
- Patients with extremity restraints are at risk for aspiration; lateral positioning is recommended.
- Ensure restraints do not interfere with medical equipment or access devices.
Personal Protective Equipment (PPE)
- PPE protects against infection spread; includes gloves, masks, goggles, face shields, gowns, and shoe covers.
- Proper PPE use is essential to prevent microorganism spread.
- Eye protection is crucial for safeguarding against splashes and respiratory droplets.
Hygiene Care for Immobile Clients
- Assess cleanliness through skin appearance and odor; check hard-to-reach areas for hygiene maintenance.
- Observe skin folds for excessive moisture and debris, ensuring areas remain dry.
Nursing Process Framework
- Systematic method of critical thinking: assessment, analysis, planning, implementation, evaluation.
Interventions for Respiratory Distress
- Implement oxygen therapy and pharmacologic interventions as per orders.
- Focus on energy conservation and nutritional therapy.
- Elevate head of the bed and assess vital signs, intake/output, and lab values.
Transferring a Patient from Wheelchair to Bed
- Lock brakes on both the bed and wheelchair; adjust bed height to wheelchair level.
- Secure wheelchair at a comfortable angle near the bed and remove leg rests if necessary.
- Assist the patient onto the side of the bed, ensuring safety and minimizing injury risk.
- Monitor water temperature and patient conditions, especially for those with impaired sensation or cognitive issues.
Bathing Procedure Guidelines
- Ensure patient privacy and gather necessary supplies; assess the patient’s tolerance and comfort.
- Utilize PPE as needed based on isolation precautions.
- Warmth and privacy during the bath are vital; maintain the patient's comfort throughout the process.
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Description
This quiz covers the essential protocols for fitting and applying compression stockings. Learn the critical measurements, application techniques, and the roles of healthcare personnel involved in the process. Ensure you understand the guidelines to provide optimal care for patients requiring compression therapy.
