Nursing Protocol for Compression Stockings

Questions and Answers

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?

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?

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?

Place it in a linen bag Signup and view all the answers

How should you proceed if a patient has an extremity injury while removing their gown?

Remove the gown from the unaffected side first Signup and view all the answers

What is the primary reason for ensuring that compression stockings are fitted correctly by a nurse?

To prevent skin irritation and maintain circulation Signup and view all the answers

Which of the following is NOT a non-pharmacological pain intervention?

Gabapentin Signup and view all the answers

What is the correct method for applying compression stockings?

Roll the stockings inside out and unroll them over the patient’s leg from toe to knee or thigh Signup and view all the answers

What must be done before applying restraints to a patient?

Confirm the patient’s identity using two identifiers Signup and view all the answers

What is a critical action to take when teaching a spouse to perform slow stroke back massages?

Teach them to perform the massage before bed Signup and view all the answers

Which item is essential to gather before applying restraints?

The necessary equipment and supplies Signup and view all the answers

What common misconception might patients have regarding therapeutic touch as a pain intervention?

It should replace all other medical treatments entirely Signup and view all the answers

Which condition would most likely require using adjuvant analgesics?

Chronic neuropathic pain Signup and view all the answers

What should be avoided when securing restraints to a patient's bed?

Attaching to the side rails Signup and view all the answers

What is the recommended method of securing restraints?

Using a quick-release tie or adjustable seat belt-like device Signup and view all the answers

What is a critical assessment that should be performed when restraints are used?

Evaluating the placement of the restraint and skin integrity Signup and view all the answers

What is the primary purpose of nursing diagnosis in the nursing process?

To identify actual or potential patient problems Signup and view all the answers

Which of the following is NOT a step in the nursing process?

Documentation Signup and view all the answers

How often should restraints be removed for assessment?

Every 2 hours or according to policy Signup and view all the answers

Which position is recommended for a patient with extremity restraints to minimize aspiration risk?

Lateral position Signup and view all the answers

Which intervention is least likely to be effective for a patient experiencing respiratory distress?

Nutritional Therapy Signup and view all the answers

During the transfer from wheelchair to bed, what is the first step to ensure safety?

Lock the wheelchair wheels Signup and view all the answers

Which device should be secure and within the patient's reach to ensure their safety?

Call light or intercom system Signup and view all the answers

What is the purpose of elevating the head of the bed when assisting a patient in respiratory distress?

To reduce exertion during breathing Signup and view all the answers

What is a key consideration when using restraints in relation to medical devices?

Restraints must not interfere with equipment, such as an IV Signup and view all the answers

What should be done with used supplies and equipment after restraint application?

Disposed of and leave the room tidy Signup and view all the answers

Which technique is important when positioning a wheelchair for transfer?

Facing the bed with wheels locked Signup and view all the answers

What kind of restraints are many health care organizations now prohibiting due to safety concerns?

Jacket (vest) restraints Signup and view all the answers

What is the primary focus of the analysis step in the clinical judgment model?

Identifying patient needs and strengths Signup and view all the answers

Which statement reflects a proper practice regarding restraint use?

Restraints must be based on a thorough patient assessment Signup and view all the answers

Which action is performed immediately after adjusting the height of the bed for transfer?

Secure the wheelchair wheels Signup and view all the answers

What key factor should be assessed to ensure a successful patient transfer from a wheelchair?

Patient's vital signs and fluid status Signup and view all the answers

What is a critical intervention for a patient with respiratory distress when monitoring vital signs?

Monitoring intake and output Signup and view all the answers

What is the primary purpose of goggles in a healthcare setting?

To shield the eyes from respiratory droplets and splashes Signup and view all the answers

Which personal protective equipment is NOT considered part of standard PPE?

Regular clothing Signup and view all the answers

What is the first step in the process of donning personal protective equipment?

Perform hand hygiene Signup and view all the answers

When removing PPE, what is the correct method for removing the mask?

Grasp the bottom ties first, then the top ties Signup and view all the answers

In what situations are airborne precautions implemented?

For patients infected with pathogens transmitted by small droplets or particles Signup and view all the answers

Which area is especially important to inspect for cleanliness in patients with limited mobility?

Areas under skinfolds Signup and view all the answers

What is the last step performed after removing all personal protective equipment?

Perform hand hygiene Signup and view all the answers

Which of the following is NOT a characteristic of face shields?

They can only be worn with masks Signup and view all the answers

What is a common mistake when removing eyewear as part of PPE?

Handling the front of the eyewear Signup and view all the answers

When cleaning a patient with mobility issues, which issue should be prioritized?

Inspecting for body odors Signup and view all the answers

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.