Study Guide For Exam #1 Watkins - final one.pdf

1.Steps on moving a patient Using A Draw Sheet 1. Move the patient with a drawsheet (two nurses): a. Place the patient supine and the head of the bed flat. With one nurse on each side of the bed, adjust its height to a position that's comfortable for both nurs...

1.Steps on moving a patient Using A Draw Sheet 1. Move the patient with a drawsheet (two nurses): a. Place the patient supine and the head of the bed flat. With one nurse on each side of the bed, adjust its height to a position that's comfortable for both nurses. b. Remove the pillow beneath the patient's head and shoulders, and place it out of the way at the head of the bed. Have the patient cross his or her arms over his or her chest. c. Roll the patient from side to side to place the drawsheet under him or her, extending the drawsheet from shoulder to thigh. Cross patient's one leg over the other to aid in rolling. d. Return the patient to the supine position. e. Stand beside the bed at the patient’s hips. The nurse on the other side of the bed also stands at the patient’s hips. Fanfold the drawsheet at the patient's sides. To do so, firmly grasp the drawsheet close to the patient. The nurse on the other side of the bed does so as well. f. Then stand with feet apart, with the foot nearest the head of the bed in front of the other foot, keeping knees and hips flexed. The other nurse assumes the same posture. On the count of three, both of you shift your weight from the back leg to the front leg and lift the patient with the drawsheet to the desired position in bed. Do not try to drag or pull the patient because doing so can cause shear or friction injury to the patient. g. Smooth out any folds or lumps in the drawsheet. 2. Hand Hygiene, Use of Gloves, Hand Sanitizer Hand Washing 1. Review the information under Safety and Comfort. 2. Make sure you have soap, paper towels, an orangewood stick or nail file, and a wastebasket. Collect missing items. 3. Push your watch and any long sleeves up your arm 4 to 5 inches. If your uniform sleeves are long, push them up too. 4. 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. 5. Turn on and adjust the water until it feels warm. 6. 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. 7. Apply about 1 teaspoon of soap to your hands. 8. 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. 9. Wash each hand and wrist thoroughly. Clean the back of your fingers and between your fingers. 10. Clean under the fingernails. Rub your fingertips against your palms. 11. 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. 12. Rinse your wrists, hands, and fingers well. Let water flow from your wrists to your fingertips. 13. Repeat steps 7 through 12, if needed. 14. Dry your wrists and hands well with clean, dry, paper towels. Pat dry starting at your fingertips. 15. Discard the paper towels into the wastebasket. 16. 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. 17. Discard the paper towels into the wastebasket. Use Of Gloves: To Apply Gloves: ​ Choose latex-free or synthetic gloves if the nurse or patient is allergic to latex, is at high risk for latex allergy, or has a suspected sensitivity to latex. 1. Gather the necessary equipment and supplies. Select the correct size and type of gloves. Examine the sterile glove package to ensure that the package is intact and dry and that the expiration date has not passed. If in doubt, get a new package of sterile gloves. Place extra sterile gloves in the operating room (OR) or procedure room before beginning the sterile procedure in case sterile gloves become contaminated or punctured and need to be changed. 2. Performed surgical hand antisepsis using surgical hand scrub or alcohol-based hand rub per the manufacturer’s instructions for use or per the organization’s practice and donned head covering, mask (if applicable), and eye protection or face shield per the organization’s practice for a sterile procedure. Inspect the condition of your hands and fingernails. Look for any cuts, lesions, or other breaks in skin integrity. If found, follow the agency’s practice for covering an open lesion with a sterile, impervious transparent dressing, as allowed. 3. To apply gloves: a. Remove the outer wrapper of the glove package by carefully separating and peeling apart the sides of the package. b. Grasp the inner glove package, and lay it on a clean, dry, flat surface that is at waist level. Open the inner package, keeping the gloves on the inside surface of the wrapper. c. Identify the right and left glove. Each glove has a cuff that is about 5 cm (2 inches) wide. You will glove your dominant hand first. d. With the thumb and the first two fingers of your nondominant hand, grasp the glove for your dominant hand at the cuff by touching only the glove’s inside surface. e. Carefully pull the glove over your dominant hand, leaving it cuffed. Be sure that the cuff does not roll up around your wrist and that your thumb and fingers are in the correct spaces.  f. With your gloved dominant hand, slip the fingers inside the cuff of the second glove. Do not touch the top surface of the cuff with your gloved hand, as this will break the sterile field. g. Carefully pull the second glove over your nondominant hand. h. After the second glove is on, interlock your hands above the level of your waist. The cuffs will usually fall down after application. Be sure to touch only the sterile sides. To dispose of gloves: i. Grasp the outside of one glove cuff with the other gloved hand; avoid touching the skin. j. Pull the glove off, away from yourself, turning it inside out and placing it in your gloved hand. k. Tuck the thumb or fingers of your bare hand inside the cuff of the remaining glove. Peel the glove off inside out and over the glove you just removed. Discard both gloves in the trash receptacle per agency practice. l. Perform thorough hand hygiene. Hand Sanitizer Using an Alcohol-Based Hand Rub 1. Review the information under Safety and Comfort. 2. Apply a palmful of an alcohol-based hand rub into a cupped hand. 3. Rub your palms together. 4. Rub the palm of 1 hand over the back of the other. Do the same for the other hand. 5. Rub your palms together with your fingers interlaced. 6. Interlock your fingers. Rub your fingers back and forth. 7. Rub the thumb of 1 hand in the palm of the other. Do the same for the other thumb. 8. 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. 9. Continue rubbing your hands until they are dry. 3. Different gates using crutches, 3 point, 2 point etc a. Walking with crutches using the three-point gait: i. 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. ii. Next, instruct the patient to move both crutches and the injured leg forward. iii. Finally, instruct the patient to move the uninjured leg forward. b. Walking with crutches using the 4-point gait: i. 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. ii. 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. c. Walking with crutches using the two-point gait: i. 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. ii. 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. d. Walking with crutches using the swing-to gait: i. 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.  ii. 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. e. Walking with crutches using the swing-through gait: i. 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. ii. 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. f. Axillary crutches: i. Ensure that the axillary crutches are the correct height for the patient. ii. Stand on the patient’s weak side, holding the gait belt firmly in one hand. iii. 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. iv. Ensure that three fingers fit in between the crutch pad and the patient’s axilla. v. Using a goniometer, adjust the handgrip so the patient’s elbow is flexed 15 to 20 degrees. vi. Follow the manufacturer’s instructions on how to adjust the height of the crutch or handgrip. g. Forearm crutches: i. Ensure that the forearm crutches are the correct height for the patient. ii. Stand on the patient’s weak side, holding the patient’s gait belt firmly in one hand. iii. 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. iv. The cuff should be approximately 1 to 2 inches below the patient’s elbow. v. Measure the patient’s forearm at the widest point to get the patient’s cuff size. vi. Follow the manufacturer’s identification bracelet 4. Assessment Data, Subjective vs Objective Collecting Objective and Subjective Patient Cues Nurses collect objective and subjective patient cues from a variety of sources during the patient assessment. Objective Pt Cues/Data: (Nurses point of view) Objective data are measurable and gathered using one of the five senses. Objective patient cues are gathered from: ​ -Observation of behaviors and interactions ​ -Physical assessment ​ -Medical record (medical history) ​ -Electronic health record (comprehensive report of overall health) ​ -Laboratory test results ​ -Diagnostic findings Examples of Objective Patient Cues: -Heart Rate is 90 beats/min -Potassium level is 4.0 mmol/L Subjective Pt Cues/Data: (Patients point of view) Subjective data are not measurable. However, objective data may substantiate the subjective data. Subjective patient cues are gathered from: ​ -Health history ​ -Reports from family members and caregivers ​ -Communication with health care team members ​ *Shift or hand-off report ​ *Clinical rounds ​ Examples of subjective patient cues: ​ -Patient states, “I have been nauseated for a week.” ​ -Patient’s son states, “My mom has been confused and forgetful.” 5. Orthostatic Hypotension a. Definition: A decrease in blood pressure upon a change in position, such as from lying to sitting to standing. Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness or dizziness) and a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 10 mm Hg within 2 to 5 minutes of quiet standing or 5 minutes of supine rest. Orthostatic hypotension occurs when patients are unable to constrict their lower extremity blood vessels to maintain their BP. Patients who are dehydrated, anemic, or have recent blood loss are at risk for orthostatic hypotension, particularly in the morning. Orthostatic changes in vital signs are effective indicators of blood volume depletion. Some medications cause orthostatic hypotension, especially in young patients and older adults. Orthostatic hypotension is a risk factor for falls, especially among older adults with hypertension. Checking for Orthostatic Hypotension: Assess for orthostatic hypotension during measurements of vital signs by obtaining BP and pulse in sequence with the patient supine, sitting, and standing. Obtain BP readings within 3 minutes after the patient changes position. In most cases orthostatic hypotension is detected within a minute of standing. If it occurs, help the patient to a lying position and notify the health care provider or nurse in charge. While obtaining orthostatic measurements, continually monitor for changes in pulse rate and observe for other symptoms of hypotension such as fainting, weakness, blurred vision, or light-headedness. Orthostatic hypotension is a risk factor for falls, especially among elderly patients who take antihypertensive medications. When recording orthostatic BP measurements, record the patient’s position in addition to the BP measurement (e.g., 140/80 mm Hg supine, 132/72 mm Hg sitting, 108/60 mm Hg standing). The skill of orthostatic blood pressure measurements cannot be delegated; this skill requires ongoing assessment and clinical judgment when anticipating the patient’s physiologic response to changing positions from lying to sitting or sitting to standing when patients are at risk for orthostatic hypotension.  6.Steps To Ambulating A Patient 1. 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 Assisting With Ambulation (Without Assist Devices) Delegation and collaboration The skill of assisting patients with ambulation can be delegated to assistive personnel (AP). The nurse directs the AP to: Apply safe patient-handling principles when assisting the patient out of bed or chair. Review steps to ensure the patient is not having orthostatic hypotension when rising from a lying position in bed to sitting. Check patient’s blood pressure before ambulation.  Immediately return a patient to the bed or chair if patient is nauseated, dizzy, pale, or diaphoretic. Report these signs and symptoms to the nurse immediately. Apply safe, nonskid shoes/socks and ensure that the environment is free of clutter and that there is no moisture on the floor before ambulating the patient. Equipment Gait/transfer belt, nonskid shoes/socks, stethoscope, sphygmomanometer, pulse oximeter (as needed), pedometer (optional) Procedural steps 1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2021). 2. Review medical record for patient’s most recent activity experience, including distance ambulated, use of assist device, activity tolerance, balance, and gait. Note history of orthostatic hypotension and any medications, chronic illnesses, gait alterations, or a history of falling. 3. Review medical record for patient’s most recently recorded weight and any descriptions of patient’s ability to stand and bear weight. STEPS TO AMBULATING PT: 1.Nurse places arm over patient’s thighs, other arm under patient’s shoulder as patient raises up.A nursing assistant places one hand under thigh and other under shoulder, with patient turned to the edge of bed toward assistant with knees flexed 2.Move patient’s lower legs and feet over side of bed as patient uses side rail to push and raise the upper body. Pivot weight onto your rear leg as you allow patient’s upper legs to swing downward.. Do not lift legs. At same time, continue to shift weight to your rear leg, and guide patient in elevating the trunk into upright position 3.Nurse shifts weight to rear leg and guides patient to raise up to sitting position.A nursing assistant raises shoulders and brings down legs simultaneously enabling patient to sit on the edge of bed. 4.Allow patient to sit on the side of the bed with feet on floor for 2 to 3 minutes (supporting back). Have patient alternately flex and extend feet and move lower legs up and down without touching floor. Ask whether patient feels dizzy; if so, check blood pressure. Have patient relax and take a few deep breaths until dizziness subsides and balance is gained. If dizziness lasts more than 60 seconds or if systolic BP has dropped at least 20 mm Hg within 3 minutes of sitting upright, return patient to bed. Recheck blood pressure. 5. If patient is alert and can bear weight and balance while standing, allow him/her to stand independently. Assist by holding gait belt to offer balance assistance. - If patient cannot bear weight or balance to stand independently but is clear to attempt ambulation, use an ambulation lift or ceiling lift with gait harness if available (see Chapter 39). Patient can walk with support of this mechanical device. 7. Confirm with patient distance to ambulate. - If patient has an IV line, place the IV pole on the same side as the site of infusion and instruct patient where to hold and push the pole while ambulating. It is best if another caregiver can push IV pole. - If a Foley catheter is present, carry the bag below the level of the bladder and prevent tension on the tubing. - For patients with orthopedic problems, stand on patient’s unaffected side. For patients with neurological deficits (e.g., stroke), stand on the affected side. For all other patients requiring assistance to maintain balance while weight bearing, stand on affected side. 8. Nurse Grasp belt firmly with one hand, palm facing up. Take a few steps, guiding patient with one hand grasping the gait belt and the other hand placed under the elbow of the patient’s flexed arm. 9.When ambulating in a hallway, position patient between yourself and the wall. Encourage patient to use handrails if available 10.Nurse helps patient by providing support under patient’s flexed arm. 11.Observe how patient walks (posture, gait, balance) and determine distance patient can safely continue walking. Measure pulse and respirations as needed. (In patients experiencing deconditioning or those ambulating for the first time, you can also measure oxygen saturation.) 12. Return patient to bed or chair (independent transfer or use of mechanical lift) and assist patient to assume a comfortable position. Place the nurse call system within patient’s reach. 13. Raise side rails (as appropriate) and lower bed to lowest position. Perform hand hygiene. 14. Dispose of any contaminated supplies in appropriate receptacle, remove and dispose of gloves, and perform hand hygiene. 33. Teach-Back: “Let us review what we discussed about taking steps in your home to have a safe path for walking. Tell me how you can prepare the rooms in your home.” Revise your instruction now or develop a plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly. 15. Record time or distance ambulated, any changes in vital signs, and patient’s tolerance (symptoms such as pain and fatigue) in nurses’ notes in electronic health record (EHR) or chart. 16. Hand-off reporting: Report to health care provider any incident of orthostatic hypotension or patient’s unexpected intolerance to exercise. 7. Assessment of Walking Patient 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. Deep Vein Thrombosis (DVT), Assessment & Interventions Deep Veing Thrombosis: Blood Clots, because of pooled blood, usually in the legs.Clot formation on venous wall Assesment & Interventions: Assessment: Swelling of affected leg or arm. Warm, cyanotic skin, dudsky toes and or pain and tenderness in affected eextremeity. Patient may complain of pain or tenderness in affected extremity a. 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. b. 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 c. If a patient has a history of DVT, measure the thighs daily because the upper thigh is also a common site for clot formation. d. Patients with limited mobility are at risk for DVT, or blood clots, because of pooled blood. e. There is a national initiative to decrease the incidence of DVT or venous thromboembolism (VTE). f. Anticoagulant therapy (heparin, enoxaparin, or warfarin) may be given prophylactically or for treatment of DVT or VTE. g. Postoperative patients, particularly those who had lower extremity surgeries, may receive anticoagulants to prevent DVT and VTE. h. 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. INTERVENTIONS BELOW Interventions: Antiembolism stockings (also called TED hose) are tight stockings made of elastic. ​ -May be knee or thigh length ​ -Do not masssage ​ -Must be fitted by nurse, but application and maintenance may be delegated to unlicensed assistive personnel ​ -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) ​ -To apply, roll the stockings inside out and unroll over the patient’s leg from toe to knee or thigh, depending upon type ​ -Fit should be snug but not painful ​ -May constrict blood flow if too small 9. Interventions for Pain 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 -Encourage Patient to take medication as ordered by health care provider -Have the Patient select nonpharmacological interventions that has relieved there pain in the past (Ex. Warm or cold Compress) -Teach spouse to preform slow stroke back massages. Instruct to preform before bed 10. Restraints (applying and key elements) Applying restraints:Gather the necessary equipment and supplies. 1. Perform hand hygiene. 2. Provide for the patient’s privacy. 3. Use a calm approach and introduce yourself to the patient, including both name and title or role. 4. Verify health care provider’s orders. Determine if signed consent is necessary. 5. Identify the patient using two identifiers, such as the patient’s name and birth date or the patient’s name and account number. 6. Explain the procedure to the patient and ensure that he or she agrees to treatment. Consult with practitioner for a patient who is uncooperative and confirm orders before proceeding. 7. Adjust the bed to the proper height, and lower the rail closest to you. Be sure that the patient is comfortable and in the correct anatomical position. 8. Inspect the area to which the restraint will be applied. Note any tubes or devices. Assess the patient’s skin integrity, sensation, circulation, and range of motion. 9. Pad the patient’s skin and bony prominences that will be covered by the restraint as necessary. 10. Apply the proper size restraint, and follow the manufacturer’s instructions for use. a. Belt restraint: Help the patient into a sitting position. Apply the belt over the patient's clothes, hospital gown, or pajamas. Smooth out wrinkles or creases in the patient’s clothing. 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 patient to a supine position if he or she is in bed. Ask the patient 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. b. Extremity (ankle or wrist) restraint: Commercially available limb restraints are made of sheepskin or foam padding. Wrap the limb restraint around  the patient’s wrist or ankle, with the soft part toward the patient’s 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. c. Mitt restraint: A thumbless hand mitt device is used to restrain a patient’s hands. Place the patient’s 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. d. Elbow restraint: This device is a rigid, padded, fabric splint that immobilizes the elbow joint. It can be removed by the patient. 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 fit of restraint. Hook clip to upper end of sleeve of patient’s gown. 11. Reminder: Attach the restraint straps to the stationary part of the bed frame. Be sure the straps are secure. Do not attach the straps to the side rails. Restraints can be attached to the frame of a chair or a wheelchair as long as the ties are out of the patient’s reach. 12. Secure the restraints with a quick-release tie, a buckle, or an adjustable seat belt-like locking device. Do not tie the straps of the restraint into a knot. 13. Double-check to make sure you can insert one or two fingers under any secured restraint (refer to the specific recommendations of the manufacturer). 14. 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. Assess the proper placement of the restraint, including the patient’s skin integrity, pulses, temperature, color, and sensation of the restrained body part. If the patient is violent or uncooperative, remove one restraint at a time, and/or have other health care team members assist you as you remove the restraints. 15. To ensure the patient's safety, secure the call light or intercom system within reach and lock the wheels on the patient’s bed or chair. Keep the bed in the lowest position, and raise the appropriate number of side rails. 16. Dispose of used supplies and equipment. Leave the patient's room tidy.  17. Remove and dispose of gloves, if used. Perform hand hygiene. 18. Document and report the patient’s response and expected or unexpected outcomes. Document the type of restraint, time applied, and reason for restraint. Key Elements for Restraintss: ​ -Because of the association with fatal injuries, many health care organizations now prohibit the use of jacket (vest) restraints. ​ -Limit the use of restraints when physically possible. Use and type of restraint must be based on a thorough assessment of the patient when other therapies have been ineffective. ​ -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. ​ -Use a quick release tie to secure the restraint. ​ -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. ​ -Do not attach the straps of a restraint to the side rails of the bed. ​ -Do not tie the straps of a restraint into a knot. ​ -Check the skin under the restraint for abrasions. ​ -Change wet or soiled restraints to prevent skin breakdown. ​ -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. ​ -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. 11. PPE- Review all Percautions. Eye Protection? 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 Personal protective equipment (PPE) is used to protect against the spread of infection. Some examples of PPE are gloves, masks, goggles, face shields, isolation gowns, head covers, and shoe covers. Proper use of PPE is essential to stop the spread of microorganisms. Eyes Protection:Goggles provide reliable eye protection from splashes, sprays, and respiratory droplets. However, goggles do not provide protection to other parts of the face. 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). Sequence for (Putting on) Donning PPE: 1.Hand Hygiene 2. Don Gown 3. Adjust Mask 4. Adjust Eyewear 5. Apply headcover 6.Apply shoe covers 7. Don Gloves Sequence for (Removing) Duffing PPE ​ 1. Gloves are removed first to prevent contaminating the face or eyes if a mask or shield was used. ​ 2. Eyewear is removed by handling earpieces and lifting away from the face. ​ 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. ​ 4.Masks are removed by grasping bottom ties or elastics, then top ties; remove without touching the front. ​ 5.Shoe covers and head covers are removed without touching hair. ​ 6.Last, hand hygiene is performed. 12. Hygiene care for client immobile Determine a patient’s level of cleanliness by observing the appearance of the skin and detecting body odors that can indicate inadequate cleansing or excessive perspiration caused by fever or pain. Inspect less obvious or difficult-to-reach skin surfaces such as under the breasts or scrotum, around the female patient’s perineum, or in the groin for redness, excessive moisture, and soiling or debris. Separate skinfolds for observation and palpation. It is important to keep these areas dry, especially in patients who are overweight. Asses, skin, mouth, foot/nail, hair andd scalp Shave the client's hair in the direction of hair growth to prevent skin irritation. Maintain bath water temperature between 43.3 C (110 F) and 46.1 C (115 F) to prevent burns. Check for personal items when changing bed linens to ensure client comfort and safety. 13. Nurse Interventions for Mitten Restraints a. Mitt restraint: A thumbless hand mitt device is used to restrain a patient’s hands. Place the patient’s 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 Abbriviations (See document on Canvas) 15.Plan Of Care & Interventions for Falls PLan of care: The planning step involves: Setting priorities based on patient problems and diagnoses Developing patient-centered goals and outcome Making clinical decisions by selecting nursing interventions Creating a personalized patient plan of care The nurse implements the plan of care and nursing interventions during the next step of the nursing process: implementation. Individualization of the plan of care based on each patient’s unique needs is one of the most important aspects of developing a plan of care during the planning stage. The order in which the nurse addresses patient problems is dependent on factors such as symptom severity and patient preference. Diagnoses direct the planning process and the selection of nursing interventions to achieve desired outcomes for patients. Intervention for Falls: a. 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. b. 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. c. 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. d. 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 ​ e. Additional measures to prevent falls include hourly rounding by nursing staff along with timely answering of call lights. f. There are positive correlations between hourly rounding and a reduction in client falls, along with an increase in client satisfaction. g. Likewise, timely answering of the client’s call light results in a reduction in client falls. - Familiarize the patient with the environment. Have the patient demonstrate call light use. Maintain call light within reach. Keep the patient’s personal possessions within patient safe reach. Have sturdy handrails in patient bathrooms, rooms, and hallways. Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. Keep hospital bed brakes locked. Keep wheelchair wheel locks in “locked” position when stationary. Keep nonslip, comfortable, well-fitting footwear on the patient. Use night lights or supplemental lighting. Keep floor surfaces clean and dry. Clean up all spills promptly. Fall prevention must be balanced with other priorities for the patient. The patient is usually not in the hospital because of falls, so attention is naturally directed elsewhere. Yet a fall in a sick patient can be disastrous and prolong recovery.  Fall prevention must be balanced with the need to mobilize patients. It may be tempting to leave patients in bed to prevent falls, but patients need to transfer and ambulate to maintain their strength and to avoid complications of bed rest. Fall prevention is one of many activities needed to protect patients from harm during their hospital stay. How should fall prevention be reinforced while maintaining enthusiasm for other priorities, such as infection control? Fall prevention is interprofessional. All health care providers need to cooperate to prevent falls. How should the right information about a patient’s fall risks get to the right member of the team at the right time? Fall prevention needs to be individualized. 16.Clostridium Difficile 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. -Organism is usually transmitted through fecal-oral route -Hands Should always be cleaned with soap and water - never sanitizer andd everyone coming in the room needs to wear gown and gloves 17 Order if Stepss of removal of PPE ^^^ UP THERE ^^^^ REFER TO #11 18. Examples of Airborne agents -Tuberculosis, Measles, Chicken Pox, Small Pox, Pneumonia, varicella, herpes zoster 19.Stages of infection ​ Stages of infection ​ 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) ​ 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. ​ 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. ​ 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 infection and Labs ​ The signs and symptoms of infection may be local or systemic. ​ 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. ​ 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. ​ 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. ​ 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. WBC- Eleveatedd white blood cell count Elevatedd Erthrocyte SSsedimentation Rate Iron Levels Cultures of Urine in blood Cultures andd gram stain of wound, sputum andd throat Labratory data: Normal Indications of Infection Neutrophils 55%-70% Increased in acute suppurative (pus-forming) infection, decreased in overwhelming bacterial infection (older adult) Lymphocytes 20%-40% Increased in chronic bacterial and viral infection, decreased in sepsis Monocytes 2%-8% Increased in protozoan, rickettsial, and tuberculosis infections Eosinophils 1%-4% Increased in parasitic infection Basophils 0.5%-1.5% Normal during infection 21. Critical Thinking what is in what step? Critical thinking is utilized throughout the entire nursing process 22. Assessment findings that require interventions by the RN  23. Body mechanics, lifting an object: ​ Raise the level of the bed to a comfortable working height ​ Keep back, neck, pelvis, and feet aligned, and avoid twisting ​ Tighten the stomach muscles and tuck the pelvis to protect your back ​ 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 & Nursing Process a. b. c. d. e. Nursing DIagnosiss: Meant to identify actual or potential patient problems In the analysis step in the clinical judgment model and implementation in the nursing process Nursing process: The systematic method of critical thinking used by nurses to develop individualized plans of care. 1.Assessment 2Anaysis 3. Planning 4.Implementation 5. Evaluation 25. Interventions for respiratory distress -Oxygen Therapy -Pharmacologic therapy (give meds as ordered) -Energy Conservation -Nutritional Therapy -Elevate the head of the bed -Assessment of vital signs, intake and output, fluid status andd lab values 26.Tranferring 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-Isolation? 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. 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. Isolation? YES Patients with scabies need to be put under CONTACT ISOLATION 28.Steps taken for syncope episode: 1. Stand with feet apart with one foot in front of the other 2. Extend one leg of the patient and let the patient slide against the leg 3.Gently lower the patient to the floor while protecting patient's head 4. Bend the knees to lower the body ass pt slides to the floor 29. Factors that can impair salivary secretions Medications, exposure to radiation, dehydration, mouth breathing can impair salivary secretions Patients may depend on their caregivers for oral care. 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. 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. These secretions often contain gram-negative bacteria that cause pneumonia if aspirated into the lungs. Proper oral hygiene requires keeping the mucosa moist and removing secretions that contribute to infection. While providing hygiene, protect the patient from choking and aspiration and use topical CHG, especially in ventilated patients (see Skill 40.3). Current evidence shows that the use of CHG with oral hygiene reduces the risk for ventilator-associated pneumonia (IHI, 2020). 30.Open Reduction Oral Fixation (ORIF) Open reduction internal fixation. 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. Contraindications: surgical incision (requires surgery) risk for infection (cuts from surgery) Indications: facilitates early ambulation 31. Complication of Fractures 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 Complications of Fracture Healing Delayed union: slow progress or failure to heal Nonunion: fracture fails to heal despite treatment Malunion: fracture heals in unsatisfactory position, resulting in deformity or dysfunction Angulation: fracture heals in abnormal position Pseudoarthrosis: false joint forms at fracture site Refracture: new fracture occurs at original fracture site Myositis ossificans: calcium deposition in muscles and muscle tissue at site of fracture -Gas Gangrene -Pulmonary Embolism -Tetanus 32.Closed Reduction A procedure that realigns a broken bone without surgery 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) closed reduction casting following reduction" refers to a medical procedure where a broken bone is realigned (reduced) without surgery, by manually manipulating it back into place, and then immobilized with a cast to maintain proper alignment and promote healing; essentially, "closed reduction" means setting the bone without making an incision, followed by applying a cast to hold it in place. Closed Reduction Manual realignment of bone fragments Traction and countertraction Casting, splints, and braces to immobilize injured part Post-reduction performed under local or general anesthesia 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 The purpose of a cast after a closed reduction procedure is to keep a fractured bone in place while it heals. Casting Temporarily circumferential mobilization device Common treatment following closed reduction Allows patient to perform daily activities while providing sufficient mobilization to restore stability Cast materials: natural (plaster), synthetic (acrylic, fiberglass), latex-free 34. Medications to Treat Muscle Spasms Central and peripheral muscle relaxants Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Methocarbamol (Robaxin) 35. Necessity for extreme traction? Extremity traction is 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: Fractures: To align bone fragments. Dislocations: To gently pull bones back into place. Muscle contractures: To relieve tension. Spinal conditions: In some cases, traction is used to relieve pressure on the spine. 36. Disposable Bed Bath ​ Assess and control the bathwater temperature, especially for patients with reduced sensation. ​ Do not soak the feet of a patient with diabetes or peripheral vascular disease. ​ To avoid injuring the eyes, ask the patient if he is wearing contact lenses. ​ Avoid using force and friction when bathing a patient. Do not massage reddened areas, especially over bony prominences. 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. ​ If one of a patient’s extremities is injured or immobilized, dress the affected side first. ​ 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. ​ Do not allow a patient with cognitive impairment or decreased orientation to shower or bathe independently. ​ Some hospitals use prepackaged disposable bed baths in place of a bath basin. 1. Verify the health care provider’s orders. 2. Gather the necessary equipment and supplies. 3. Provide for patient privacy. 4. Perform hand hygiene. 5. Introduce yourself to the patient and family, if present. 6. 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. 7. Explain the procedure to the patient and ensure that he or she agrees to the treatment. 8. Encourage the patient to void prior to beginning the bath. Offer the patient a bedpan or urinal. Provide a towel and washcloth. 9. 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. 10. Arrange all supplies on the overbed table. Position a waste container and a laundry hamper close to the patient’s bed. 11. 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. 12. Raise the bed to a comfortable working height. Lower the near side rail. 13. 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. 14. Remove the patient’s gown or pajamas, using the bath blanket or towel to cover exposed areas of the patient’s body. a. If the gown has snaps at the sleeves, unsnap them and remove the gown without pulling on the IV tubing. b. If an extremity is injured or has reduced mobility, undress the unaffected side first. c. 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. i. 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. ii. 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. 15. 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. 16. Remove a single premoistened cloth from the warmed package and begin by cleansing the face and neck. 17. 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. 18. Cover the patient’s chest and abdomen with the bath blanket or towel, leaving the arm on the near side exposed. 19. Remove a clean cloth from the package and cleanse the exposed arm and hand. Cleanse the axilla last. Apply deodorant if desired. 20. Raise the side rail, then move to the opposite side of the bed and lower the side rail. 21. Using a clean cloth, cleanse the other arm and hand in the same manner. 22. 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. 23. Expose the near leg, ensuring that the perineal area and the other leg remain draped. 24. 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. 25. Using a clean cloth, cleanse the foot, paying special attention to the area between the toes. Cleanse and file the nails as needed. 26. Use a clean dry towel to dry the toes and foot completely. 27. Cover the cleansed leg and raise the side rail. 28. Move to the opposite side of the bed and lower the side rail. 29. Expose the other leg and foot. Cleanse them with a clean cloth, provide nail care as needed, and dry the toes and foot. 30. Cover the cleansed leg and foot. 31. 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. a. 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. b. Assist the patient as needed into a side-lying position to cleanse the buttocks. c. Keep the patient draped by sliding the bath blanket or towel over the shoulders and thighs. d. 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. 32. Remove a clean cloth from the package and cleanse the patient’s back using long, firm strokes. 33. Assist the patient into a comfortable position. 34. 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. 35. Raise the side rail. 36. Remove gloves and perform hand hygiene. 37. Give a back rub if the patient desires, donning clean gloves if needed. See the video skill on performing a back massage. 38. Assist the patient with grooming. Comb the patient’s hair. Be aware that female patients might wish to apply cosmetics. 39. Apply gloves and make the patient’s bed. 40. Remove soiled linen and place it in the dirty linen bag. Do not allow linen to contact your uniform. 41. Clean and replace bathing equipment. 42. Return the waste container and laundry hamper to their original locations. 43. Remove gloves and perform hand hygiene. 44. Check the function and position of external devices, such as indwelling catheters, nasogastric tubes, intravenous tubes, and braces. 45. 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.  46. Dispose of used supplies and equipment. 47. Perform hand hygiene. 48. Document and report the patient’s response and expected or unexpected outcomes. 37. Muscle Spasm Drug Therapy Central and peripheral muscle relaxants Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Methocarbamol (Robaxin)