Patient Care Documentation and Safety Protocols

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Questions and Answers

What vital information should be documented after applying Montgomery straps?

Chronological history of past wounds

The procedure, patient response, and wound assessment (correct)

The patient's diet and activity level

Only the type of dressing applied

Which factor is NOT essential when evaluating a patient for moving them in bed?

The patient's body weight

The patient’s ability to understand directions

The weather conditions outside (correct)

Any activity restrictions the patient has

When should assistive devices be used for lifting a patient?

When the patient complains of pain

When the caregiver feels fatigued

When the patient requires more than 35 pounds of lifting (correct)

When the patient is able to walk unassisted

What is the primary purpose of patient identification before a procedure?

To validate the procedure for the correct patient Signup and view all the answers

What task may be delegated to nursing assistive personnel when moving a patient?

Moving the patient up in bed Signup and view all the answers

What is the primary benefit of using friction-reducing sheets during patient handling?

To prevent skin tears and reduce injury risk Signup and view all the answers

Why is it important to close the curtains and door around the patient's bed?

To provide privacy for the patient Signup and view all the answers

Which of the following is a critical consideration before delegating patient handling tasks?

The qualifications of the person being delegated to Signup and view all the answers

What is the recommended bed height when preparing for a procedure?

At the caregiver's elbow height Signup and view all the answers

What is the effect of placing the bed in a slight Trendelenburg position?

Supports movement for both patient and caregiver Signup and view all the answers

How should documentation related to a patient's dressing care be maintained?

Thoroughly, including patient responses and wound assessments Signup and view all the answers

What role does the Safe Patient Handling Algorithm play in patient movement?

It provides a framework for decision-making in patient handling Signup and view all the answers

Why should pillows be removed from under the patient except for one at the head?

To facilitate movement and prevent headboard injury Signup and view all the answers

What role do side rails play during patient repositioning?

They minimize strain on the nurses while moving the patient Signup and view all the answers

What is the purpose of using a friction-reducing device under the patient?

To support the patient’s weight and reduce friction Signup and view all the answers

How can a patient assist with their own movement during a procedure?

By bending their legs and pushing with their feet Signup and view all the answers

What is the primary purpose of assessing the patient’s level of consciousness before moving them?

To ensure the patient can follow directions and assist with movement Signup and view all the answers

Which equipment is necessary if indicated based on patient assessment?

Friction-reducing sheet Signup and view all the answers

What nursing diagnosis is directly related to a patient’s difficulty with moving in bed?

Activity Intolerance Signup and view all the answers

Why is it important to assess for tubes, IV lines, and incisions during the patient movement process?

To prevent injury and determine the best movement plan Signup and view all the answers

What does the outcome of a patient maintaining proper body alignment indicate?

The patient is free from injury during movement Signup and view all the answers

What action must be performed before handling a patient?

Perform hand hygiene and put on PPE if indicated Signup and view all the answers

In assessing the patient's skin, what signs should you look for?

Irritation, redness, edema, or blanching Signup and view all the answers

What is the rationale for utilizing a patient handling algorithm?

To assist in planning an appropriate approach to moving the patient Signup and view all the answers

What is the purpose of having the patient fold their arms across the chest during repositioning?

To assist in reducing friction and hyperextension of the neck Signup and view all the answers

Why is it important for nurses to position themselves at the patient's midsection with feet spread shoulder width apart?

To lower their center of gravity and reduce injury risk Signup and view all the answers

How does engaging a mechanism to make the bed surface firmer assist in patient repositioning?

It decreases friction and effort needed to move the patient Signup and view all the answers

What technique should be used to prevent back injury during patient transfer?

Using the legs' large muscle groups and keeping the back straight Signup and view all the answers

What benefit does it provide if the patient assists in their own move up in bed?

It lessens the effort exerted by the nurses Signup and view all the answers

What is the purpose of readjusting the bed height and providing support after positioning the patient?

To ensure patient safety and comfort Signup and view all the answers

What action should be taken regarding the side rails after repositioning the patient?

Raise the side rails for safety Signup and view all the answers

What is the criteria for placing the bed in the lowest position after care?

To enhance safety for the patient and prevent falls Signup and view all the answers

Study Notes

Documentation

Document the procedure, patient response, and assessment before and after applying Montgomery straps.
Note the wound description, drainage amount and character, and surrounding skin assessment.
Document the dressing type applied, including skin protectant and barrier.
Record Montgomery strap application for dressing security.
Document patient response to dressing care and pain assessment.
Include pertinent patient and family education.

Patient Moving

Safe patient handling is paramount when repositioning.
Consider the patient’s condition, restrictions, ability to assist, and body weight to determine assistance needed.
This task should not be performed by one person.
Safe Patient Handling Algorithm 4 in Skill 173 can guide decisions.
Use assistive devices when lifting more than 35 pounds of patient weight.

Moving a Patient Up in Bed

It may be delegated to nursing or unlicensed assistive personnel, as well as LPN/LVNs.
Delegate based on patient needs and qualifications of the personnel.

Equipment

Friction-reducing sheet or other friction-reducing device.
Full-body sling lift and cover sheet, if necessary, based on assessment.
Nonsterile gloves, if indicated, and other PPE as needed.
Additional caregivers based on assessment.

Assessment

Determine the need to move the patient up in bed.
Review the medical record and care plan to identify influencing factors on the patient's ability to move.
Assess for tubes, IV lines, incisions, or equipment that may impact positioning.
Assess level of consciousness, understanding, and ability to follow directions.
Determine weight and caregiver strength to establish the number of caregivers needed.
Assess for the need for bariatric equipment.
Check the patient's skin for irritation, redness, edema, or blanching.

Nursing Diagnosis

Activity Intolerance.
Risk for Injury.
Impaired Bed Mobility.

Outcome Identification and Planning

Patient remains free from injury and maintains proper body alignment.
Patient reports improved comfort.
Patient's skin is clean, dry, and intact, without redness, irritation, or breakdown.

Implementation Actions and Rationale

Reviewing the medical record and nursing plan of care: Validates the correct patient and procedure; identifies limitations and assists in preventing injury and determining the best plan.
Hand hygiene and PPE: Prevents the spread of microorganisms; required based on transmission precautions.
Identify the patient and explain the procedure: Validates the correct patient and procedure; allays anxiety and prepares the patient.
Prepare the bed environment: Provides for privacy; ensures proper bed height to reduce back strain; flat positioning decreases gravitational pull of the upper body; Trendelenburg position aids movement.
Remove pillows but leave one at the head: Facilitates movement; prevents head injury.
Position nurses on each side of the bed and lower side rails: Facilitates moving the patient and minimizes strain on nurses.
Place a friction-reducing sheet under the patient: Supports weight and reduces friction during repositioning.
Ask the patient to bend legs and place feet flat on the bed: Assists with movement and prevents skin shearing on the heels.
Have the patient fold arms across the chest and lift the head with chin to chest: Provides assistance, reduces friction, and prevents neck hyperextension.
Position nurses opposite the center of body mass, feet shoulder width apart, one foot slightly in front: Lowers the center of gravity and reduces the risk of injury for the nurses.
Engage the bed mechanism to provide a firmer surface: Decreases friction and effort needed to move the patient.
Grasp the friction-reducing sheet securely, close to the patient’s body: Brings the patient's center of gravity closer to the nurses and provides a secure hold.
Flex knees and hips; tighten abdominal and gluteal muscles; keep back straight: Prevents back injury.
Patient assists by pushing with legs, if possible: Lessens the effort required by nurses.
Rocking motion while moving the patient: Uses nurses' weight to counteract the patient's weight; develops momentum for a smooth lift with minimal exertion.
Adjust the patient's position; readjust pillows and supports: Ensures patient safety and comfort.
Return bed to normal setting; raise side rails; lower the bed: Enhances safety and facilitates patient access to essential items.

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Description

This quiz covers essential documentation practices for patient care, including the application of Montgomery straps and assessing patient responses. It also emphasizes safe patient handling and the delegation of tasks for moving patients, ensuring both patient safety and effective care. Ideal for nursing students or healthcare professionals.