N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 113 of 160 is a flat panel of plastic or wood that keeps the feet in dorsiflexion to prevent plantar flexion. Trochanter rolls are folded towels rolled up next to the trochanter that prevent hip flexion in the prone client. Other supportive devices are splints and handrails. Transfer Techniques • Lying to sitting : Assist the client to a lateral position facing you and raise the head of the bed slowly as high as it will go. Stand beside the client’s hips, place one arm around the client’s shoulders, and the other beneath the client’s thighs. Tighten your gluteal, abdominal, leg, and arm muscles. Lift the client’s thighs slightly and pivot on the balls of your feet in the desired direction. Pull the client’s feet and legs off the bed. Support the client until the client is well balanced and comfortable. • Bed to chair : Lock the bed and wheelchair. Assist the client to a sitting position at the side of the bed. Assist with bathrobe and nonskid slippers (barriers). Thoroughly instruct client. Assist the client to stand, and move together toward the wheelchair. Support the client in an upright standing position for a few moments to extend the joints. Pivot or take a few steps toward the wheelchair. Assist the client to sit. Assistive Devices • Walkers : Ensure the client has adequate strength to lift the walker. Adjust the height of the hand bar to just below waistline. • Canes : These should have rubber caps for traction. Adjust the height so the elbow is just slightly flexed. • Crutches : Require suction tips to prevent slipping and adjust for required height and handbar. Teach the appropriate stance and gait. Teach appropriate transfer techniques. The weight of the body should be on the arms and not the armpits. Preventing injuries: Teach safe transfer and ambulation techniques. Teach the use of proper body mechanics. Discuss safety measures such as locking wheelchairs, wearing appropriate footwear, use of rubber tips on crutches, and keeping the environment safe (no rugs to trip over, etc.) Use mechanical aids such as a raised toilet seat, grab bars, urinal, and bedpan or bedside commode. Interventions to Promote Activity and Mobility Positioning: position (semi sitting position) is where the head and trunk are raised 45-90 degrees. Too many pillows in this position can promote the development of neck flexion contractures. Supine or dorsal recumbent position is used to provide comfort and to facilitate healing following certain surgeries or anesthetics. Prone is lying on the abdomen with the head turned to one side. This is especially useful for unconscious clients because it promotes drainage from the mouth, preventing aspiration. It is used only with the back properly aligned and for short periods of time. Sims position is halfway between the lateral and the prone positions. This is used in the unconscious and paralyzed (paraplegic or hemiplegic) clients because it reduces pressure over the sacrum and greater trochanter of the hip. Supportive devices: A footboard The preferred method is to have two or more people move or turn the client. Fowler’s