Real 170 A Study Guide.pdf

Real 170 A Study Guide They are crazy for assigning us all this work, we are crazier for doing it. 1. Steps on moving a patient using a draw sheet: a. Use lifting and transfer devices when available. b. Use a friction-reducing device if any HC...

Real 170 A Study Guide They are crazy for assigning us all this work, we are crazier for doing it. 1. Steps on moving a patient using a draw sheet: a. Use lifting and transfer devices when available. b. Use a friction-reducing device if any HC team member will be expected to lift >35 pounds of the Px body weight. Do not start the procedure until all required health care team members are at the bedside. c. The person with the heaviest load coordinates the efforts of the personnel involved in lifting or transferring. d. Determine if the patient can fully or partially assist. e. Ensure that the brakes are locked on the bed and the stretcher. f. Position an assistant at the head of the bed to protect and support the head and neck if the patient is weak or unable to assist with the transfer. g. Use appropriate body mechanics to avoid injury of the nursing staff. h. Keep the weight to be lifted as close to the body as possible; this action places the weight in the same plane as the lifter and close to the center of gravity for balance. i. The best height for vertical lifting is approximately 2 feet off the ground and close to the lifter's center of gravity. j. Know the pathological conditions that affect a patient's body alignment and mobility. Postural abnormalities affect body mechanics. k. Control factors that indirectly affect body mechanics by altering the safety of the environment. Determine the number of staff required to transfer the patient safely from the bed to a stretcher using a horizontal slide board or other friction-reducing device. At least 2 assistants are needed for any type of transfer. A third assistant is recommended to support the head and neck if the patient is weak or unable to assist during the transfer. Raise the bed to a comfortable height.  Make sure the bed brakes are locked. Lower the head of the bed as much as the patient can tolerate. Support the patient’s head as you remove the pillow. Lower the side rails of the bed. Cross the patient’s arms over his or her chest. On the count of three, turn the patient onto his or her side toward the two nurses. Turn the patient as a single unit, with a smooth, continuous motion. Fanfold the draw sheet on both sides. Place the slide board under the waterproof pad and draw sheet. Gently roll the patient back onto the slide board. Adjust the position of the patient to center his or her weight onto the slide board. Line up the stretcher with the bed, setting the stretcher one half inch lower than the bed. Lock the brakes on the stretcher. Two nurses position themselves on the side of the stretcher, while the third nurse is positioned on the side of the bed without the stretcher. On the count of three, the two nurses pull the fan folded draw sheet, with the patient, onto the stretcher as the third nurse holds the slide board. Position the patient in the center of the stretcher and remove the slide board from under the patient. Raise the side rails on the stretcher. Raise the head of the stretcher if doing so is not contraindicated. Cover the patient with a blanket. Remove PPE and perform hand hygiene. Document the procedure, including any pertinent observations, such as signs of weakness and the patient’s ability to follow directions and assist. Inform the next shift or other health care team members of any assistance that might be needed. 2. Hand hygiene, use of gloves, hand sanitizer: a. Hand Washing: Review the information under Safety and Comfort.  Make sure you have soap, paper towels, an orangewood stick or nail file, and a wastebasket. Collect missing items. Push your watch and any long sleeves up your arm 4 to 5 inches. If your uniform sleeves are long, push them up too. Stand away from the sink so your clothes do not touch it and so the soap and faucet are easy to reach. Do not touch the inside of the sink at any time. Turn on and adjust the water until it feels warm. Wet your wrists and hands. Keep your hands lower than your elbows. Be sure to wet the area 3 to 4 inches above your wrists. Apply about 1 teaspoon of soap to your hands. Rub your palms together and interlace your fingers to work up a good lather. Lather your wrists, hands, and fingers. Keep your hands lower than your elbows. Wash for at least 15 to 20 seconds. Wash each hand and wrist thoroughly. Clean the back of your fingers and between your fingers. Clean under the fingernails. Rub your fingertips against your palms. Clean under the fingernails with a nail file or orangewood stick. Do this at the first hand washing of the day and when your hands are highly soiled. Rinse your wrists, hands, and fingers well. Let water flow from your wrists to your fingertips. Repeat steps 7 through 12, if needed. Dry your wrists and hands well with clean, dry, paper towels. Pat dry starting at your fingertips. Discard the paper towels into the wastebasket. Turn off faucets with clean, dry paper towels. This prevents you from contaminating your hands. Use a clean paper towel for each faucet. Or use knee or foot controls to turn off the faucet. Discard the paper towels into the wastebasket. b. Using Alcohol-Based Hand Rub Review the information under Safety and Comfort.  Apply a palmful of an alcohol-based hand rub into a cupped hand. Rub your palms together. Rub the palm of 1 hand over the back of the other. Do the same for the other hand. Rub your palms together with your fingers interlaced. Interlock your fingers. Rub your fingers back and forth. Rub the thumb of 1 hand in the palm of the other. Do the same for the other thumb. Rub the fingers of 1 hand into the palm of the other. Use a circular motion. Do the same for the fingers on the other hand. Continue rubbing your hands until they are dry. c. Use of Gloves: Find Correct size, apply hand hygiene before, be aware of latex allergies Pull the first glove w/ dominant hand w/ the glove dominant hand slip your fingers beneath the cuff of the second glove, then interlock your hands & hold them above your waist leve 3. Different gates using crutches, 3-point, 2-point: a. Walkers: Ensure that the walker is the correct height and width for the patient. Have the patient stand inside the frame of the walker while the nurse holds the patient’s gait belt firmly in one hand. The walker is at the correct height when the top of the walker lines up with the crease on the side of the patient’s wrist. When the patient places his or her hands on the grips of the walker, the patient’s elbows should be flexed between 15 and 30 degrees. If the patient’s hips are too wide for him or her to easily step into the walker, obtain a wider walker. b. Axillary crutches: Ensure that the axillary crutches are the correct height for the patient. Stand on the patient’s weak side, holding the gait belt firmly in one hand. Position the base of each crutch 15 centimeters (or 6 inches) to the side and 15 centimeters (or 6 inches) in front of the patient’s feet. Ensure that three fingers fit in between the crutch pad and the patient’s axilla.  Using a goniometer, adjust the handgrip so the patient’s elbow is flexed 15 to 20 degrees. Follow the manufacturer’s instructions on how to adjust the height of the crutch or handgrip. c. Forearm crutches: Ensure that the forearm crutches are the correct height for the patient. Stand on the patient’s weak side, holding the patient’s gait belt firmly in one hand. The height of the handgrip should be at the crease of the patient’s wrist when the patient’s arms are extended and the patient’s arms should be bent at a 30 degree angle when the patient holds the hand grips. The cuff should be approximately 1 to 2 inches below the patient’s elbow. Measure the patient’s forearm at the widest point to get the patient’s cuff size. Follow the manufacturer’s identification bracelet. d. Canes: To walk with a cane, have the patient move the cane forward 15 to 25 centimeters (6 to 10 inches). Then have the patient move the weaker leg forward, even with the cane. Instruct the patient to move the stronger leg forward 15 to 25 centimeters (6 to 10 inches) past the cane. Then move the weaker leg forward, even with or slightly past the stronger leg. As the patient becomes more comfortable with the cane, encourage the patient to move the cane and the weaker leg at the same time, so they strike the ground simultaneously. e. Walking with crutches using the 2-point gait: Stand behind the patient and slightly to the side, holding the gait belt firmly in one hand. Have the patient begin in the tripod position with his or her weight distributed at least partially on both feet. Next, instruct the patient to move his or her left foot and the right crutch forward, followed by his or her right foot and the left crutch. *hand grips should be at the waist line f. Walking with crutches using the 3-point gait: Stand behind the patient and slightly to the side, holding the gait belt firmly in one hand. Have the patient begin in the tripod position with all weight on the uninjured leg.  Next, instruct the patient to move both crutches and the injured leg forward. Finally, instruct the patient to move the uninjured leg forward. g. Walking with crutches using the 4-point gait: Have the patient begin in the tripod position, with the patient’s feet parallel and the crutches 15 centimeters (or 6 inches) to the sides and 15 centimeters (or 6 inches) in front of the patient’s feet. Stand behind the patient and slightly to the side, holding the gait belt firmly in one hand. Instruct the patient to move the right crutch forward 10 to 15 centimeters (4 to 6 inches), then move his or her left foot forward until it is parallel with the left crutch. Next, have the patient move the left crutch forward 10 to 15 centimeters (4 to 6 inches), then move his or her right foot forward until it is parallel with the right crutch. h. Walking with crutches using the swing-to gait: Stand behind the patient and slightly to the side, holding the gait belt firmly in one hand. Instruct the patient to begin in the tripod position with his or her weight distributed at least partially on both feet. Next, have the patient advance both crutches, then lift and swing both legs to the crutches, letting the crutches support the patient’s weight entirely. i. Walking with crutches using the swing-through gait: Stand behind the patient and slightly to the side, holding the gait belt firmly in one hand. Instruct the patient to begin in the tripod position with his or her weight distributed at least partially on both feet. Next, have the patient advance both crutches, then lift and swing both legs past the crutches, letting the crutches support the patient’s weight entirely. j. Climbing stairs with crutches: To climb stairs with crutches, instruct the patient to start at the bottom of the stairs in the tripod position. Hold the patient’s gait belt securely, and have the patient transfer all weight to the crutches and use the uninjured leg to step up onto the first stair.  Instruct the patient to straighten the knee on the uninjured leg and lift his or her body weight bringing the crutches and injured leg up onto the stair. Repeat sequence of steps until the patient reaches the top of the stairs. k. Descending stairs with crutches: To descend stairs with crutches, instruct the patient to start in the tripod position, and then shift body weight onto the uninjured leg. Have the patient bend the strong knee while moving the crutches and injured leg to the stair below, shift body weight onto the crutches, and then step down onto the stair with the uninjured leg. l. Rising from a chair with crutches: Instruct the patient to move to the edge of the chair and place the weak leg forward and the stronger leg between the chair’s legs and slightly under the chair seat. Hold the patient’s gait belt, and have the patient hold both crutches in one hand on the injured side and use both crutches and the opposite chair arm to provide leverage to stand. If the chair is lightweight or unstable, the patient should use both chair arms to prevent the chair from tipping. Once standing, instruct the patient to transfer one crutch to the strong side. m. Sitting in a chair with crutches: Hold the patient’s gait belt and have the patient back up until the patient feels the seat of the chair against the back of his or her legs, then move the weak leg forward and balance on the strong leg. Have the patient transfer both crutches to one hand on the injured side. Instruct the patient to grasp the arm of the chair with his or her free hand and lower body onto the seat. 4. Assessment data (Objective and Subjective): a. Subjective Data: information collected from the patient’s point of view; cannot be objectively measured. Symptoms (e.g., back pain or fatigue) Verbal  Feelings Concerns Perceptions Generally gathered during an interview or health history Documented in the medical record using quotation marks b. Objective Data: information collected via what is seen, measured, or tested. Signs (e.g., skin rash or lump) - Observable - Generally collected from physical assessment (inspection, palpation, percussion, and auscultation), medical records, diagnostic tests, and laboratory findings 5. Orthostatic (Postural) Hypotension: a. Definition: A decrease in blood pressure upon a change in position, such as from lying to sitting to standing. b. Contributing Factors: Vasodilation causes blood to pool in lower extremities rather than being returned to the heart Aging Certain medication side effects, especially blood pressure medication Prolonged immobility Dehydration Anemia (low red blood cells) c. It is a drop in Systolic pressure of at least 20 mm Hg or a drop in diastolic pressure by at least 10 mm Hg within 3 minutes of rising to an upright position. d. Patients also experience symptoms of dizziness, lightheadedness, nausea, tachycardia, pallor, or fainting when changing from the supine to standing position. 6. Steps to ambulating a patient: a. Obtain and become familiar with the gait belt to be used. b. Assess the patient to make sure he or she is rested and not fatigued. c. Obtain extra personnel to assist with ambulation if necessary. d. Place bed in the low position with the bed wheels locked. e. Address the patient’s fear of falling if present. f. Use safety precautions before and during ambulation to control orthostatic hypotension and subsequent falling. For example, if the patient has been lying in bed, have him or her dangle the legs over the side of the bed before ambulating. g. Before getting the patient up to walk, help him or her put on safe, nonskid shoes, make sure the environment is clutter free, and check to see that the floor is dry. h. Remove obstacles from the pathways, including throw rugs, and wipe up any spills immediately. Avoid crowds. Crowds increase the risk that the patient will lose balance. i. If the patient becomes weak or dizzy, help him or her return to bed or to a chair, whichever is closer to the patient. j. If the patient begins to fall, gently ease him or her to the floor by holding firmly onto the gait belt, standing with your feet apart to provide a broad base of support, extending one leg, and letting the patient gently slide to the floor. As the patient slides, bend your knees to lower his or her body. k. Assisted ambulation with one nurse: Stand and grasp the gait belt in the middle of the patient’s back. Help the patient to a standing position; be sure to observe the patient’s balance. Before beginning ambulation, reconfirm that the patient does not feel lightheaded. If needed, make additional arrangements to accommodate such things as a continuous IV infusion by obtaining a portable IV pole. Be sure urinary drainage bags are carried below the level of the bladder. Have the patient take a few steps while you stand on the patient’s stronger side. If an assistive device such as a cane or walker is being used, then stand on the patient’s weaker side. Take a few steps forward with the patient. Then assess the patient for strength and balance. If the patient becomes weak or dizzy, return him or her to the bed or a chair, whichever is closer. If the patient begins to fall, gently ease him or her to the floor by holding firmly onto the gait belt, standing with your feet apart to provide a broad base of support, extending your leg, and letting the patient gently slide to the floor. As the patient slides, bend your knees to lower his or her body.  l. Assisted ambulation with two nurses: Before beginning ambulation, reconfirm that the patient does not feel lightheaded. Help the patient into a sitting position and snugly apply the gait belt. Help the patient to a standing position; be sure to observe the patient’s balance. Stand on one side of the patient, and have another nurse or assistant stand on the other side. Both you and the other nurse will grasp the walking belt in the middle of the patient’s back. Step forward in unison with the patient, keeping your speed and step size the same as the patient’s. Gradually increase the distance walked. If the patient becomes weak or dizzy, return him or her to the bed or a chair, whichever is closer. If the patient begins to fall, gently ease him or her to the floor by holding firmly onto the gait belt, standing with your feet apart to provide a broad base of support, extending your leg, and letting the patient gently slide to the floor. As the patient slides, bend your knees to lower his or her body. m. Help the patient into a comfortable position, and place toiletries and personal items within reach. n. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. o. To ensure the patient's safety, raise the appropriate number of side rails and lower the bed to the lowest position. p. Dispose of used supplies and equipment. Leave the patient's room tidy. q. Remove and dispose of gloves, if used. Perform hand hygiene. r. Document and report the patient’s response and expected or unexpected outcomes. 7. Assessment of patient walking: a. Have the patient take a few steps while you stand on the patient’s stronger side. b. If an assistive device such as a cane or walker is being used, then stand on the patient’s weaker side. c. Take a few steps forward with the patient. d. Then assess the patient for strength and balance.  e. If the patient becomes weak or dizzy, return him or her to the bed or a chair, whichever is closer. 8. DVT - Assessment and Interventions: a. Deep Vein Thrombosis: Clot formation on venous wall b. Signs of a DVT: Usually occur on one side of the body at a time Including swelling in the affected leg or arm Warm, cyanotic skin; and pain or tenderness in the affected extremity. A patient may complain of cramping or soreness. If a DVT is suspected, keep the patient calm and quiet in bed and notify the health care provider. c. Measure bilateral calf circumference and record it daily as an alternative assessment for DVT. To do this, mark a point on each calf 10 cm down from the mid patella. d. Measure the circumference each day, using this mark for placement of the tape measure. Unilateral increases in calf circumference are an early indication of thrombosis e. If a patient has a history of DVT, measure the thighs daily because the upper thigh is also a common site for clot formation. f. Patients with limited mobility are at risk for DVT, or blood clots, because of pooled blood. g. There is a national initiative to decrease the incidence of DVT or venous thromboembolism (VTE). h. Anticoagulant therapy (heparin, enoxaparin, or warfarin) may be given prophylactically or for treatment of DVT or VTE. i. Postoperative patients, particularly those who had lower extremity surgeries, may receive anticoagulants to prevent DVT and VTE. j. Antiembolism stockings and sequential compression devices (SCDs) both apply pressure to the calf muscle to promote venous blood return and decrease the risk for DVT. k. Interventions: Anti Embolism stockings (also called TED hose) are tight stockings made of elastic. 1. May be knee or thigh length  2. Must be fitted by nurse, but application and maintenance may be delegated to unlicensed assistive personnel 3. Must measure the length (knee: heel to space behind the knee; thigh: heel to gluteal fold) and width (knee: biggest part of calf; thigh: biggest part of calf and thigh) 4. To apply, roll the stockings inside out and unroll over the patient’s leg from toe to knee or thigh, depending upon type 5. Fit should be snug but not painful 6. May constrict blood flow if too small 7. May constrict blood flow or cause skin irritation if wrinkles or bunching occurs 8. Monitor patient’s skin integrity and circulation in toes while wearing stockings 9. Do not massage extremity because this could dislodge the clot 9. Interventions of pain (info from ATI Planning care for client experience pain page 5) a. Non Pharmacological Pain Interventions: Positioning Cutaneous Stimulation; cold, hot, touch, massage, acupuncture, acupressure, and transcutaneous electrical stimulations ←(TENS) CBT; distraction, relaxation, imagery, and music therapy. Therapeutic Touch; nurse utilizes the hands either on or near the body of the client to balance client’s energy and promote healing. This treatment has been noted to help alleviate or reduce pain and alleviate psychological symptoms for patients with cancer or fibromyalgia b. Pharmacological Interventions Opioids; natural, semisynthetic, and synthetic/ morphine, codeine, fentanyl Nonopioid analgesics; NSAIDS, Acetaminophen, sucrose for sick infants. Adjuvant analgesics; corticosteroids, gabapentin, carbamazepine, antidepressants, and botulinum toxin c. Side note for pain interventions: Nurses must assess and reassess continually after each treatment or intervention, keeping the client’s goals in mind documenting their findings upon evaluation. 10. Restraints (applying and key elements) a. Because of the association with fatal injuries- many hospitals have prohibited the use of jacket (vest) restraints. b. Limit the use of restraints when physically possible. c. Use and type should be based on a thorough assessment when other therapies have been ineffective. d. Place the patient in the lateral position, or elevate the head of the bed. The patient with extremity restraints is at risk for aspiration if placed in the supine position. e. Use a quick release tie to secure the restraint. f. Ensure that the restraint does not interfere with equipment, such as an IV, and is not placed over an access device, such as an arteriovenous shunt. g. Do not attach the straps of a restraint to the side rails of the bed. h. Do not tie the straps of a restraint into a knot. i. Check the skin under the restraint for abrasions. j. Change wet or soiled restraints to prevent skin breakdown. k. Remove a restraint immediately if the patient has an alteration in neurovascular status of an extremity, such as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling, pain, or numbness in the restrained extremity. l. Because of the risk of aspiration, do not restrain a patient who requires a face mask on noninvasive positive pressure ventilation (NPPV). The patient should be able to remove the mask in the event of vomiting. m. Remove the restraints at least every 2 hours or according to your organization’s policy for time specifications for restraint removal, and assess the patient each time. n. Secure a call light near pt. o. Caution family against removing, repositioning, or retying restraint. p. The initial assessment of pt for restraint NEEDS to be done by a nurse and not delegated to NAP. AFTERWARDS application and routine checking of a restraint, however, can be delegated to NAP. The Joint Commission Requires that anyone who monitors a restrained patient, including NAP, be trained in first aid. Be sure to inform NAP of the following: q. Correct placement of the restraint and how to routinely check the patient’s circulation, skin condition, and breathing. r. When and how to change a patient’s position or provide range-of-motion exercises, toileting, and skin care. s. To notify you immediately if there is a change in the level of the patient’s agitation, skin integrity, circulation of the extremities, or breathing. t. After applying a restraint, evaluate the patient’s condition for signs of injury every 15 minutes. u. for a patient with violent or self-destructive behavior, a licensed health care provider must evaluate the patient in person within 1 hour of initiating the restraint. v. Older adults with dementia or altered mental status are at higher risk for use of restraints during hospitalization w. Types of restraints: Belt restraint: Help the PT into a sitting position. Apply the belt over the patient's clothing. Smooth out wrinkles or creases. Be sure to place the restraint at the waist, not the chest or the abdomen. Bring the ties through the  slots in the belt. Avoid applying the belt too tightly. Assist the PT to a supine position if he/she is in bed. Ask the PT to take a deep breath to ensure there is no restriction to breathing. Attach the restraint securely to a stationary part of the bed frame. Extremity (ankle or wrist) restraint: Wrap the limb restraint around the PT wrist or ankle, with the soft part toward the PT skin, and secure it snugly, but not tightly, by using the Velcro straps or clips. Check to make sure the restraint is not too tight by inserting one finger under the secured restraint. Secure the strap through the D-ring. Use a quick release tie to secure the restraint to the stationary part of the bed frame. Mitt restraint: A thumbless hand mitt device is used to restrain a patient’s hands. Place the PT hand in the mitt, making sure that the Velcro strap(s) are around the patient’s wrist, and not the forearm. Check to see that one finger slides easily beneath the restraint. Elbow restraint: This device is a rigid, padded, fabric splint that immobilizes the elbow joint. It CAN be removed by the PT. This will help the patient stop picking at an IV line. Place restraint around the patient’s arm so the elbow joint rests against the padded area. Keeping the elbow rigid, secure splint with Velcro straps. Check the fit of restraint. Hook clip to upper end of sleeve of patient’s gown. 11. PPE- review all precautions. Eye precautions? a. ALERT: Don appropriate PPE based on the patient’s signs and symptoms and indications for isolation precautions. Determine whether the patient has a known or suspected airborne transmissible disease. Wear respiratory protection, such as an N95 respirator or disposable particulate respirator, when caring for a patient with a known or suspected airborne transmissible disease. Wear PPE when the anticipated patient interaction indicates that contact with blood or bodily fluids may occur. Wear gloves when it is likely that you will touch blood, bodily fluids, secretions, excretions, non intact skin, mucous membranes, or contaminated items or surfaces. Remove your gloves and perform hand hygiene between patient care encounters and when moving from a contaminated body site to a clean one. Perform hand hygiene with soap and water or use an alcohol-based hand rub (ABHR) immediately after removing all PPE. Use synthetic nonlatex gloves with patients at high risk for or with known or suspected sensitivity to latex. Nurses who have sensitivity or allergy to latex should also use nonlatex gloves.  Hypoallergenic, low-powder, and low-protein latex gloves may still contain enough latex protein to cause an allergic reaction. Protect fellow health care workers from exposure to infectious agents through proper use and disposal of equipment. Place patients who require airborne isolation in a negative-pressure airborne infection isolation room (AIIR). If an AIIR is not available, place a surgical mask on the patient. The door to the isolation room and the anteroom should NEVER be open at the same time. b. Eye protection, such as goggles or glasses, protect the membranes of the eyes, while face shields protect the entire face when performing tasks that could generate splashes or sprays of blood or other bodily fluids c. Precautions: Airborne Precautions: 1. Airborne precautions are implemented for patients infected with known or suspected pathogens that can be transmitted by small droplets or particles. 2. Patients enter through a separate entrance to the facility, if available, to avoid the reception and registration area. 3. Patient immediately placed in an airborne infection isolation room (AIIR). 4. PPE use: a. A fit-tested N95 or higher-level disposable respirator is worn when caring for the patient. The respirator is donned before room entry and removed after exiting the room. b. Gowns, gloves, and goggles or face shields are worn if substantial spraying of respiratory fluids is anticipated. c. Patients wear a facemask when exiting the room, avoiding close contact with other patients, and practicing respiratory hygiene/cough etiquette. 5. Conditions for which airborne precautions are required: a. Varicella or disseminated varicella zoster (chickenpox) b. Rubeola (measles) c. Mycobacterium tuberculosis (pulmonary or laryngeal tuberculosis) DROPLET PRECAUTIONS: 1. Droplet precautions are implemented for patients who are known or suspected to be infected with an infectious pathogen that can be transmitted by respiratory droplets. 2. Droplet transmission of pathogens can occur through coughing, sneezing, talking, suctioning, endotracheal intubation, cardiopulmonary resuscitation (CPR), or chest physiotherapy. 3. Patients are placed in a single patient room with a closed door as soon as possible, prioritizing patients with excessive cough and sputum production.  4. If a private room is not available, the patient is provided with a facemask and placed in a separate area as far from other patients as possible. 5. PPE use: a. Facemask, such as a procedure or surgical mask, for close contact with the patient; the facemask is donned upon entering the patient’s room. b. If substantial spraying of respiratory fluids is anticipated, gloves, gown, and goggles (or face shield in place of goggles) are worn. c. Patient wears a facemask when exiting the room and follows respiratory hygiene/cough etiquette. 6. Conditions for which droplet precautions are required: a. Pharyngeal diphtheria b. Mumps, rubella, and pertussis c. Streptococcal pharyngitis and scarlet fever d. Pneumonias (streptococcal, mycoplasma, meningococcal) e. Pneumonic plague f. Meningococcal sepsis g. Influenza CONTACT PRECAUTION: 1. Contact precautions are implemented to prevent transmission of known or suspected infectious agents directly or indirectly from one patient or person to another. 2. Contact transmission of pathogens can occur through: a. Direct contact with the patient b. Indirect contact with equipment or items in the patient’s environment 3. Precautions include: a. Single patient room or cohorting of patients with similar risk factors (e.g., stool incontinence, same infection) if a single room is not available b. PPE use upon entry into room and discarding upon exit to contain pathogens c. Gloves when touching the patient and the patient’s immediate environment or belongings d. Gown if substantial contact with patients or their environment is anticipated 4. Conditions for which contact precautions are required: a. Multidrug-resistant organisms (MDROs), including vancomycin-resistant Enterococcus, methicillin-resistant Staphylococcus aureus, Clostridium difficile, respiratory syncytial virus, and hepatitis A b. Scabies and herpes simplex virus (HSV) c. Excessive wound drainage d. Fecal incontinence with potential for environmental contamination and risk for transmission 12. Hygiene care for client immobile 13. Nurse interventions for mitten restraints  a. Mitt restraint: A thumbless hand mitt device is used to restrain a patient’s hands. Place the PT hand in the mitt, making sure that the Velcro strap(s) are around the patient’s wrist, and not the forearm. Check to see that one finger slides easily beneath the restraint. 14. Medical abbreviations 15. Plan of care & interventions for falls a. Factors that may contribute to a client falling include physical disorders, such as the following: Stroke Amputation Recent surgery Multiple sclerosis Visual impairment Chronic pain Malnutrition Weakness Unsteady gait b. Cognitive influences that may contribute to a client falling include: Sleep disorders Impulsiveness Disorientation Dementia Depression c. Environmental factors that may contribute to a client falling include: Room clutter Poor lighting Slippery floors d. Still other factors that may contribute to a client falling include: The use of certain medications—such as antidepressant, antihypertensive, and anticonvulsant drugs—that have a strong correlation with client falls Age Bathroom frequency, with or without incontinence The staffing levels on the unit​​ e. Clients at Risk for Falling A fall is defined as an “unplanned descent to the floor with or without injury”. In the United States, every 11 seconds, an older adult client receives medical treatment for a fall, and every 19 minutes, an older adult client dies from injuries related to a fall. In the hospital setting, between 700,000 and 1 million client falls occur every year.  Falls can add 6 to 12 days to the hospitalization and add $30,000 of direct cost per client. f. Falls can have a negative effect on a client's ability to function independently and falls can decrease their quality of life. g. TJC requires each hospital to have a fall prevention policy and procedure. Beginning generally with a fall risk screening and assessment ​and an evaluation of the client’s environment. The nurse should take steps to ensure the client’s environment is safe by clearing the environment of any hazards that may result in slipping or tripping, using ergonomics, and ensuring the client’s bed is at a proper height when transferring from a bed to chair, or from a bed to a standing position. h. A fall risk screening tool should be used to evaluate all clients upon arrival and admission to the hospital, in both outpatient and inpatient settings. i. The nurse usually performs this task. Any item that is answered as “yes” by the client during the initial screening would then necessitate further assessment by the nurse using a fall risk assessment tool to determine an individualized plan of care for the client to prevent falls. Several valid fall risk screening and fall assessment tools are available, and nurses need to become familiar with the tools used in the facility in which they practice. There is no evidence on how often screening or assessment for falls should be conducted with clients; thus, the frequency of screening may vary from one facility to another. Nurses need to be familiar with their facility’s policy and adhere to it to ensure client safety. j. Collectively, all hospitalized clients should have fall prevention mechanisms in place or universal fall precautions. These should consist of the following. Use of non-skid footwear Keeping the bed in the low position Locking the wheels of beds Placing the brakes on wheelchairs Maintaining a clutter-free environment Adequate lighting Placing the call light and belongings within clients’ reach Fall prevention education for clients, along with basic orientation to the room and call light system ​ k. Additional measures to prevent falls include hourly rounding by nursing staff along with timely answering of call lights.  l. There are positive correlations between hourly rounding and a reduction in client falls, along with an increase in client satisfaction. m. Likewise, timely answering of the client’s call light results in a reduction in client falls. 16. Clostridium Difficile:produces symptoms ranging from mild diarrhea to severe colitis. a. Most common healthcare–related infection in America. b. Patients acquire C. difficile infection in one of two ways: by antibiotic therapy that causes an overgrowth of C. difficile and by contact with the C. difficile organism. c. Patients are exposed to the organism from a health care worker’s hands or direct contact with environmental surfaces contaminated with it. d. Only hand hygiene with soap and water is effective to physically remove C. difficile spores from the hands. e. Older adult patients are especially vulnerable to C. difficile infection when exposed to antibiotics, and higher mortality and morbidity are observed in this age-group. f. Patients with C. difficile are placed on contact/enteric isolation precautions. A private room with a dedicated toilet is preferred to help prevent transmission to other patients. 17. Order of steps removal of PPE a. PPE is removed to prevent contaminating the face, hair, and clothing. Step 1. Gloves are removed first to prevent contaminating the face or eyes if a mask or shield was used. Step 2. Eyewear is removed by handling earpieces and lifting away from the face. Step 3. Gowns are removed by untying the waist strings, then the neck strings, then grasping the shoulders and pulling them down and out, and then rolling the gown from outside to inside into a ball. Step 4. Masks are removed by grasping bottom ties or elastics, then top ties; remove without touching the front. Step 5. Shoe covers and head covers are removed without touching hair. Step 6. hand hygiene is performed. 18. Example of airborne agents a. Varicella or disseminated varicella zoster (chickenpox) b. Rubeola (measles) c. Mycobacterium tuberculosis (pulmonary or laryngeal tuberculosis) 19. Stages of infection a. Incubation Period: Interval between entrance of pathogen into body and appearance of first symptoms. (e.g chickenpox 14 to 16 days after exposure; common cold 1 to 2 days) b. Prodromal Stage: Interval from onset of nonspecific signs and symptoms(malaise, low grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and the patient may be capable of spreading  disease to others). For example, herpes simplex begins with itching and tingling at the site before the lesion appears. c. Illness Stage: Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain and swelling; mumps is manifested by high fever and parotid gland swelling. d. Convalescence: Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient’s host resistance; recovery may take several days to months.) 20. Signs and symptoms of infections, labs a. The signs and symptoms of infection may be local or systemic. b. Localized infections: Most common in areas of skin or mucous membrane breakdown, such as surgical and traumatic wounds, pressure injuries, oral lesions, and abscesses. Local infections are confined to one area of the body. These infections can be treated with topical antibiotics and oral antibiotics. To assess an area for localized infection, first inspect it for redness, warmth, and swelling caused by inflammation. Infected drainage may be yellow, green, or brown, depending on the pathogen. For example, green nasal secretions often indicate a sinus infection. Ask the patient about pain or tenderness around the site. c. Systemic infections: Start as local infections and then move into the bloodstream, from which they infect the entire body. Intravenous antibiotics and careful monitoring are both needed to treat systemic infections.\ Systemic infections cause more generalized symptoms than local infection. These symptoms often include fever, fatigue, nausea/vomiting, and malaise. Lymph nodes that drain the area of infection often become enlarged, swollen, and tender during palpation. For example, an abscess in the peritoneal cavity causes enlargement of lymph nodes in the groin. If an infection is serious and widespread, all major lymph nodes may enlarge. Systemic infections sometimes develop after treatment for localized infection has failed. As systemic infections develop, an elevation in body temperature can lead to episodes of increased heart and respiratory rates and low blood pressure. d. Examples: A pulmonary infection results in a productive cough with purulent sputum. A UTI results in cloudy, foul-smelling urine. Patients diagnosed with a UTI are typically prescribed a urinalysis (UA). An infection does not always present with typical signs and symptoms in all patients. For example, in some older adults an infection may be advanced before it is identified.  As many as 20% of older adults with pneumonia do not have the typical signs and symptoms of fever, shaking, chills, and colored productive sputum. e. Blood Tests determine the presence and severity of infection, by reviewing the WBC count and differential. The presence of increased WBCs indicates inflammation or infection. The WBC count is a measure of all the combined WBCs in the body, but the differential will show each individual type of WBC: neutrophils, lymphocytes, monocytes, eosinophils, and basophils (listed here in order of most prevalent to least prevalent). WBCs make up about 1% of the blood cells in the body but are crucial for immunity. The higher the WBC count, the more severe the infectious process has become. Decreased WBC counts (below the expected range) indicate that the body has a decreased ability to fight infections. Neutropenia (abnormally low WBC count) can be very dangerous, with lower numbers indicating that the body is unable to fight infections at all and is vulnerable to further infection. f. Laboratory data: Review laboratory data as soon as the results are available. Laboratory values such as increased WBCs and/or a positive blood culture often indicate infection. 21. Critical Thinking is in what step? 22. Assessment findings that require interventions by the RN 23. Body mechanics, lifting an object: a. Raise the level of the bed to a comfortable working height b. Keep back, neck, pelvis, and feet aligned, and avoid twisting c. Tighten the stomach muscles and tuck the pelvis to protect your back d. Bend at the knees and let the strong muscles of the legs do the lifting the person with the heaviest load coordinates the efforts of the personnel involved in the transferring 24. Nursing diagnosis & the nursing process a. b. c. d. e. f. Key Points: The nursing process is a systematic method of critical thinking used by nurses to develop individualized plans of care and provide care for patients. The nursing process consists of five steps: 1. Assessment 2. Analysis  3. Planning 4. Implementation 5. Evaluation The steps of the nursing process are interdependent; each step requires information from the others for adequate development of an effective plan of care. 25. Interventions for respiratory distress 26. Transferring from wheelchair to bed a. Lock the bed brakes and wheelchair wheels. Secure the wheelchair wheels by pushing the handles forward on the locks, which are located above the wheel rims. b. Adjust the height of the bed to the level of the wheelchair seat. c. Place the wheelchair facing toward the foot of the bed, midway between the head and the foot of the bed. d. Position the wheelchair at a comfortable angle to the bed on the same side on the patient's stronger side. e. Secure the wheels by pushing the handles forward on the locks above the wheel rims. f. Raise the footrests and swing the leg rests outward on the wheelchair. g. You may remove the leg rests before transferring the patient to avoid trips and falls. h. Sit the patient up on the side of the bed by doing the following: With the patient supine, raise the head of the bed 30 degrees. Turn the patient on to his or her side facing you, on the side of bed on which the patient will be sitting. Stand opposite the patient's hips. Turn diagonally, so that you face the patient and the far corner of the foot of the bed. Create a wide base of support by spreading your feet apart, with the foot that is closer to the head of the bed in front of your other foot. Slip your arm that is nearer the head of the bed under the patient's shoulders, supporting the head and the neck. Place your other arm over the patient's thighs. Move the patient's lower legs and feet over the side of the bed by pivoting toward your back leg, allowing the patient's upper legs to swing down. At the same time, shift your weight to your back leg and lift the patient on the side of the bed. i. Help the patient move to the edge of the mattress. j. Allow the patient to sit on the side of the bed, legs dangling, for a few minutes before transferring him or her to a wheelchair. Do not leave the patient unattended during this time. Ask if the patient feels dizzy. k. Help the patient apply stable, non skid shoes. Place the patient's weight-bearing, or stronger, leg forward, with the weaker foot to the back. l. Place the transfer belt on the waist of the patient, over the gown.  m. With the tag of the belt touching the patient's gown, slide the metal trimmed end of the gait belt through the teeth on the other end. Pull the metal trimmed end away from the teeth. Tighten the belt until snug on the patient's center of gravity. The belt should be tight enough for 2 fingers to slide into the belt. n. Spread your feet. Flex your hips and knees, and align your knees with those of the patient. o. Grasp the transfer belt along the patient's sides. p. Position yourself slightly in front of the patient, to guard and protect him or her throughout the transfer. q. On the count of three, rock the patient up to a standing position by straightening your hips and legs, keeping your knees slightly flexed. r. While rocking the patient in a back-and-forth motion, make sure your body weight is moving in the same direction as the patient's body weight. Unless contraindicated, ask the patient to push up off the mattress. s. Maintain the stability of the patient's weak or paralyzed leg with your knee, and pivot on the foot that is farther from the wheelchair. t. Instruct the patient to feel for the edge of the wheelchair seat against the legs and to use the armrests for support as you ease him or her into the wheelchair. u. Flex your hips and knees while lowering the patient into the wheelchair. v. Ensure that the patient is positioned well back in the seat. Provide support to the extremities if needed. Ensure proper alignment in a sitting position. w. Lower the footrests after transferring the patient, and place the patient's feet on them. x. Provide comfort measures for the patient and ensure that the call light is within reach. y. Place a blanket over the patient's legs, if needed. z. Monitor the patient's vital signs as needed. Ask if the patient feels dizzy or fatigued. Note the patient's behavior during the transfer. Remain in front of the patient until he or she regains balance. Continue to provide physical support to a weak or cognitively impaired patient. aa. Document how long the patient was on the chair and the care provided in the EMR. 27. Scabies-isolations? a. Scabies: skin infestation caused by tiny mites called Sarcoptes scabiei var hominis. These microscopic parasites burrow into the skin to live and lay eggs, leading to intense itching and a rash. The condition spreads through close physical contact, making it highly contagious. b. Symptoms of Scabies: Itching: Often severe, particularly at night. · Rash: Small red bumps or blisters, sometimes in lines. · Burrows: Tiny, raised tracks on the skin made by the mites. · Common areas affected: Between fingers, wrists, elbows, waist, armpits, and genital area c. Infestations: It typically takes 2 to 6 weeks after initial exposure to scabies mites for symptoms to appear. This period is known as the incubation period. During the incubation period, the immune system is developing a response to the mites, which leads to the development of symptoms. In cases where a person has had scabies before, symptoms can appear much sooner, often within 1 to 4 days of re-exposure. This quicker onset occurs because the immune system is already sensitized to the mites from a previous infestation. d. How It Spreads: Scabies are primarily transmitted through direct, prolonged skin-to-skin contact with an infected person. Households: Living with someone who has scabies can lead to transmission due to shared spaces and frequent contact. Sexual contact: Scabies are often spread between sexual partners due to prolonged physical contact. Crowded conditions: Places like nursing homes, schools, prisons, and daycare centers can see rapid outbreaks because of frequent close contact. Sharing personal items: While less common, scabies can sometimes be transmitted through sharing items like clothing, towels, or bedding that have been in contact with the mites. Children: Those in daycare centers, schools, or other settings with frequent close contact. Elderly: Especially in nursing homes or long-term care facilities, where scabies can spread quickly. Healthcare workers: Those caring for individuals with scabies, particularly in outbreak settings, are at risk of exposure. Immunocompromised individuals: People with weakened immune systems (e.g., those with HIV/AIDS or undergoing chemotherapy) are at higher risk for severe forms of scabies, such as crusted (Norwegian) scabies. e. Medical Treatments: Topical Treatments: 1. Permethrin cream (5%): This is the most prescribed treatment. It kills both mites and their eggs and is applied to the entire body, left on for 8-14 hours, and then washed off. 2. Benzyl benzoate: Another topical lotion that kills mites. 3. Crotamiton cream or lotion: Used less frequently, but also prescribed for scabies. 4. Sulfur ointment: Sometimes prescribed for pregnant women or infants.  Oral Treatment: 1. Ivermectin: An oral antiparasitic medication used in severe or widespread cases, or when topical treatments are ineffective. It’s especially useful in outbreaks or for individuals with crusted scabies. 2. These treatments are typically applied to the entire body and left on for several hours, usually overnight, to ensure all mites and eggs are killed. Environmental Treatment: 1. Washing clothing, bedding, and towels: Items used by the infected person should be washed in hot water (at least 60°C or 140°F) and dried at high heat to kill any mites that may be present. 2. · Sealing non-washable items: Items that cannot be washed, like pillows or stuffed animals, can be sealed in plastic bags for at least 3 to 7 days, which will starve the mites as they cannot survive long without human skin. Without a Host: 1. Scabies mites cannot survive without human skin for more than 2-3 days. They die of dehydration and starvation when not in contact with a human host. 2. Proper treatment of both the infected person and their environment is essential to prevent reinfestation. It's important to treat everyone in the household simultaneously to prevent reinfestation. f. Diagnosis: Physical Examination: The provider will inspect the skin for characteristic signs, such as burrows, rash, and itching. 1. During a physical examination for scabies, a healthcare provider looks for specific signs and symptoms indicative of the infestation. Here’s how they assess scabies: Inspection of Skin Lesions: 1. Burrows: The provider looks for tiny, thread-like, grayish or reddish lines on the skin. 2. Rash and Lesions: The provider examines the rash, which may include small red bumps, blisters, or papules and often appears in clusters. Assessment of Symptom Patterns: Link to the 28~36 question: link ⬅️ 28. Steps to be taken for the syncope episode a. If the patient begins to fall, gently ease him or her to the floor by holding firmly onto the gait belt.  b. Stand with your feet apart to provide a broad base of support, extending your leg, and let the patient gently slide to the floor. c. As the patient slides, bend your knees to lower his or her body. 29. Factors that can impair salivary secretions a. Medications b. Exposure to radiation c. Mouth breathing can impair salivary secretion d. Patients may depend on their caregivers for oral care. e. Being unconscious or having an artificial airway (e.g., endotracheal or tracheal tubes) increases the susceptibility for patients to have drying of salivary secretions because they are unable to eat or drink, unable to swallow, and frequently breathe through the mouth. f. Unconscious patients often have a reduced gag reflex, or they cannot swallow salivary secretions that accumulate in the mouth. Pooling of salivary secretions in the back of the throat harbors microorganism growth. g. These secretions often contain gram-negative bacteria that cause pneumonia if aspirated into the lungs. h. Proper oral hygiene requires keeping the mucosa moist and removing secretions that contribute to infection. i. While providing hygiene, protect the patient from choking and aspiration and use topical CHG, especially in ventilated patients (see Skill 40.3). j. Current evidence shows that the use of CHG with oral hygiene reduces the risk for ventilator-associated pneumonia (IHI, 2020). 30. Open reduction internal fixation ORIF a. Open Reduction Internal Fixation (ORIF) It's a surgical procedure that repairs broken bones by stabilizing them with metal fasteners. ORIF is used to treat severely displaced or open bone fractures, where the fracture has pierced the skin. b. Surgical incision (requires surgery) c. Risk for infection (cuts from surgery) d. Facilitates early ambulation 31. Complications of fractures a. A fracture is a disruption of bone tissue continuity. Fractures most commonly result from direct external trauma, but they also occur as a consequence of some deformity of the bone. b. Pulmonary Embolism: is caused by a blocked artery in the lungs. The most common cause of such a blockage is a blood clot that forms in a deep vein in the leg and travels to the lungs, where it gets lodged in a smaller lung artery. Fractures of the femur and tibia are associated with the highest risk of PE.  Trauma and surgery can activate clotting factors and cause immobility, which can then lead to PE. c. Gas Gangrene: is a severe and potentially fatal infection (caused by bacteria in the genus Clostridium) that can occur as a complication of open fractures and deep wounds that compromise blood supply. The tibia and fibula are most commonly involved but gas gangrene can also occur after fractures of the femur, ankle, knee and pelvis. d. Tetanus: is a life-threatening infection caused by the bacteria clostridium tetani, which enters the body through wounds, especially puncture wounds. Fractures that break the skin can increase the risk of tetanus infection. It is important to treat open fractures early to reduce the risk of infection. 32. Closed reductions a. Closed reduction is a non-surgical method for managing a simple fracture. b. Moderate sedation (local or general anesthesia) is used during this procedure for patient comfort. c. A pulling force (traction) is applied manually to realign the displaced fractured bone fragments. d. Once the fracture is reduced, immobilization is used to allow the bone to heal. (lecture PP & Med-surg textbook) 33. Purpose of cast a. The purpose of a cast is to immobilize a broken, dislocated joint, or severe sprain to allow it to heal properly. b. By holding the affected area in a fixed position, a cast helps ensure that the bones or tissues remain aligned, reducing pain, preventing further injury, and promoting proper healing. Temporary Allows patient to perform many normal activities of daily living Typically incorporates joints above and below fracture 34. Medications to treat muscle spasms a. Central and peripheral muscle relaxants Carisoprodol (Soma) oral: is a centrally-acting skeletal muscle relaxant. Carisoprodol is FDA-approved for alleviating the discomfort associated with acute, painful musculoskeletal conditions. Cyclobenzaprine (Flexeril) oral: relieves skeletal muscle spasms of local origin without interfering with muscle function. Methocarbamol (Robaxin) oral: is a type of muscle relaxant that works by calming overactive nerves in your body 35. Necessity for extremity traction? a. Extremity traction commonly used in orthopedic care to align and stabilize fractures, reduce pain, and prevent muscle spasms.  It helps maintain proper bone positioning during the healing process. Traction may be necessary in cases like: b. Fractures: To align bone fragments. c. Dislocations: To gently pull bones back into place. d. Muscle contractures: To relieve tension. e. Spinal conditions: In some cases, traction is used to relieve pressure on the spine. 36. Disposable bed bath a. Assess and control the bathwater temperature, especially for patients with reduced sensation. b. Do not soak the feet of a patient with diabetes or peripheral vascular disease. c. To avoid injuring the eyes, ask the patient if he is wearing contact lenses. d. Avoid using force and friction when bathing a patient. Do not massage reddened areas, especially over bony TUDT. Massage of the legs is also contraindicated, because a blood clot may be present and could become dislodged. Do not use massage for pressure ulcer prevention. e. If one of a patient’s extremities is injured or immobilized, dress the affected side first. f. Protect the patient from injury by assessing and controlling the bathwater temperature. This is especially important for older adult patients and those with reduced sensation, such as patients who have diabetes, peripheral neuropathy, or spinal cord injuries and for those who cannot communicate. g. Do not allow a patient with cognitive impairment or decreased orientation to shower or bathe independently. h. Some hospitals use prepackaged disposable bed baths in place of a bath basin. Verify the health care provider’s orders. Gather the necessary equipment and supplies. Provide for patient privacy. Perform hand hygiene Introduce yourself to the patient and family, if present. Identify the patient using two identifiers, such as name and date of birth or name and account number, according to agency policy. Compare these identifiers with the information on the patient’s identification bracelet. Explain the procedure to the patient and ensure that he or she agrees to the treatment. Encourage the patient to void prior to beginning the bath. Offer the patient a bedpan or urinal. Provide a towel and washcloth. Assess the patient's tolerance for bathing and activity, comfort level, cognitive ability and musculoskeletal function. Assess for shortness of breath. Before or during the bath, assess the condition of the patient's skin Arrange all supplies on the overbed table. Position a waste container and a laundry hamper close to the patient’s bed  Perform hand hygiene and apply clean gloves. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or risk of exposure to bodily fluids Raise the bed to a comfortable working height. Lower the near side rail Place a bath blanket or towel over the patient to provide warmth and privacy during the bath. Have him or her hold the top of it. Remove the top sheet from under the bath blanket or towel without exposing the patient. Place soiled linen in a linen bag. Remove the patient’s gown or pajamas, using the bath blanket or towel to cover exposed areas of the patient’s body. 1. If the gown has snaps at the sleeves, unsnap them and remove the gown without pulling on the IV tubing. 2. If an extremity is injured or has reduced mobility, undress the unaffected side first. 3. If the patient has an IV line and a gown with no snaps, first remove the gown from the arm without the IV line. Then remove the gown from the arm with the IV line. 4. If intravenous fluids are infusing by gravity, unhook the IV container from the pole and slide the tubing and IV container through the arm of the patient’s gown. Rehang the IV container on the pole, and check the intravenous flow rate and regulate it if necessary. Do not disconnect the intravenous tubing to remove the gown. 5. If an IV pump is in use, turn it off, clamp the tubing, and remove the tubing from the pump. Unhook the IV container from the pole and slide the tubing and IV container through the arm of the patient’s gown. Rehang the IV container on the pole, then reinsert the tubing into the pump, unclamp it, and turn the pump on at the correct rate. Reestablish the appropriate flow rate if necessary. Warm the contents of a package of disposable cloths per the manufacturer’s instructions for use. Use a clean cloth for each area of the body to be cleansed. Use caution around IV sites, dressings, and nonintact skin. Remove a single pre moistened cloth from the warmed package and begin by cleansing the face and neck. Fold the bath blanket or towel that is over the patient’s chest down to the umbilicus. Obtain a clean cloth and cleanse the chest and abdomen using long, firm strokes. Take special care with the skin under a female patient’s breasts, lifting each breast upward, if necessary, using the back of the hand. Cover the patient’s chest and abdomen with the bath blanket or towel, leaving the arm on the near side exposed.  Remove a clean cloth from the package and cleanse the exposed arm and hand. Cleanse the axilla last. Apply deodorant if desired. Raise the side rail, then move to the opposite side of the bed and lower the side rail. Using a clean cloth, cleanse the other arm and hand in the same manner. Help the patient into a clean gown or pajama top, dressing the affected side first. If necessary, omit this step until the bath is complete. Cover the patient with a clean bath blanket or towel, placing the soiled linen in a linen bag. Expose the near leg, ensuring that the perineal area and the other leg remain draped. Remove a clean cloth from the package and cleanse the exposed leg, using long, firm strokes from the ankle to the knee and then from the knee to the thigh. Assess the leg for signs of DVT, such as warmth, redness, discoloration, swelling, tenderness, or pain. Using a clean cloth, cleanse the foot, paying special attention to the area between the toes. Cleanse and file the nails as needed. Use a clean dry towel to dry the toes and foot completely. Cover the cleansed leg and raise the side rail. Move to the opposite side of the bed and lower the side rail. Expose the other leg and foot. Cleanse them with a clean cloth, provide nail care as needed, and dry the toes and feet. Cover the cleansed leg and foot. Provide perineal care. Remove a clean cloth from the package and cleanse the perineal area or allow the patient to cleanse the area if he or she is able. Use an extra pack of fresh disposable cloths or use washcloths with soap and water, and towels if needed, for excessive soiling. 1. For a male patient, cleanse around the penis. For a female patient, cleanse the outer and inner labia. See the video skills on performing male and female perineal care. 2. Assist the patient as needed into a side-lying position to cleanse the buttocks. 3. Keep the patient draped by sliding the bath blanket or towel over the shoulders and thighs. 4. If fecal material is present, enclose the waste in a fold of underpad or toilet tissue. Additional disposable bath cloths may be needed for cleansing. Dispose of the tissue or wipes in the appropriate waste container. Remove a clean cloth from the package and cleanse the patient’s back using long, firm strokes. Assist the patient into a comfortable position. If not done previously, assist the patient as needed with donning a clean gown, pajamas, or other clothing as applicable. Dress the affected side first.  Raise the side rail. Remove gloves and perform hand hygiene. Give a back rub if the patient desires, donning clean gloves if needed. See the video skill on performing a back massage. Assist the patient with grooming. Comb the patient’s hair. Be aware that female patients might wish to apply cosmetics. Apply gloves and make the patient’s bed. Remove soiled linen and place it in the dirty linen bag. Do not allow linen to contact your uniform. Clean and replace bathing equipment Return the waste container and laundry hamper to their original locations. Remove gloves and perform hand hygiene. Check the function and position of external devices, such as indwelling catheters, nasogastric tubes, intravenous tubes, and braces. Replace the call light, and neatly arrange personal possessions. To ensure the patient’s safety, place the bed in the locked, low position with at least two but no more than three side rails raised. Make sure the patient is as comfortable as possible. Dispose of used supplies and equipment. Perform hand hygiene. Document and report the patient’s response and expected or unexpected outcomes.