Head of bed raised to 45 degree angle up to 90 degrees Semi sitting to full upright sitting position Used for eating/drinking to prevent aspiration and to promote full lung expansion

Semi/Low fowlers

Head of bed raised approx. 30 degrees Used for patients who cannot tolerate fowler's/high fowler's or position is ordered after lumbar puncture

Trendelenburg's

Entire bed tilted downward toward head of bed Facilitates removal of secretions with postural drainage, venous return in patients with poor peripheral circulation, sometimes used to aid in dilation of large vessels for central line placement

Reverse trendelenburg's

Entire bed frame tilted downward toward foot of bed Not commonly used; promotes gastric emptying and prevents esophageal reflux, Facilitates arterial circulation to lower extremities

Flat

Bed is parallel with floor Used for vertebral injuries, immediately after lumbar puncture, and in cervical traction Preferred by patients for sleeping

Explain a cool water tub bath

An option to relieve tension or lower body temp Water temp is tepid, 98.6F (37C) Cold water should not be used-causes chilling and shivering

Explain a warm water tub bath

Used to reduce muscle tension Water temp. is approx. 110F (43C)

Explain a hot water tub bath

Relieves muscle soreness and muscle spasms Not recommended for children Proper water temp. for adults = 113F (45C) to 115F (46C)

Explain a sitz bath

Cleanses and aids in reducing inflammation of perineal and anal areas

Describe skin care data collection

Good turgor (elastic/firm); generally smooth and soft Intact without abrasions Localized changes in texture across surface Skin color variants from body part to body part Warm/moist

Good nursing interventions involved with pressure ulcers and pressure injuries can result in what?

Optimal healing of impaired skin without complications Decrease in patient's discomfort Decrease in length of stay at facility Decrease in cost of ongoing care

Shearing force

Tissue layers of skin slide on each other causing subcutaneous blood vessels to kink or stretch and resulting in an interruption of blood flow to the skin

Friction

Rubbing of skin against another surface produces friction which may remove layers of tissue

Stages of pressure injury development

1. Localized area of skin, typically over a bony prominence, that is intact with non-blanchable redness 2. Partial thickness, loss of dermis, looks like blister 3. Full thickness tissue loss, subcutaneous fat is sometimes visible -Hardest layer to heal due to lack of capillaries 4. Full thickness tissue loss with exposed bone, tendon, cartilage or muscle

Suspected deep tissue pressure injury

Wound appears as a localized purple or maroon area of discolored intact skin or a blood filled blister

What temperatures can the body's thermoreceptors generally adapt well to?

59F (15C) and 113F (45C)

Explain what heat and cold applications are used for

Heat: provide comfort and speed healing Cold: Decrease swelling and reduce pain

What are warm soaks used for?

Increase circulation to the affected area, reduce edema, aid in the debridement of wounds, relax muscles, and can be used to apply medical solution to large areas Temp. 105F (40.5C) to 110F (43C)

What are cold compresses used for?

Used to treat inflammation and prevent edema Can be either clean or sterile Apply for 20 min at 59F (15C)

What can ice packs be used for?

Reduce edema formation, bleeding, provide an anesthetic effect to areas of hemorrhage and hematoma formation, for patients who have undergone dental surgery

Anticoagulant therapy

Meds that increase the tendency to bleed

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