21 terms

body mechanics/hygiene

Factors for risk of skin alterations
1. dehydration
3. decreased sensation = spinal cord injury, nerve damage, diabetic neuropathy, other neuropathies
4. therapeutic measures = bed rest, casts, medications (allergic reactions, dryness)
hygiene care: early morning
shortly after awakening to refresh the patient and prepare for breakfast or diagnostic tests
hygiene care: am care
after breakfast assist w/toileting, oral care, bathing, back massage, special skin care measures, hair care, dressing and positioning
self care, partial care, complete care
hygiene care: afternoon care
hygiene care: HS care
hours of sleep care
assist w/toileting, washing of face & hands, oral care, back massage, change any soiled linens or clothes, make sure they have call light & other things they need are close at hand
hygiene care: prn care
as needed care
purposes of bathing
1. cleanses/condition skin
2. relax a restless person
3. promote circulation by stimulating the skin's peripheral nerve endings & underlying tissue
4. promotes musculoskeletal exercise
5. promotes comfort
6. gives nurse opportunity to assess the patient
patient comfort
1. linens are clean and wrinkle free
2. patient feels comfortable warm
3. at risk patient's pressure points are protected
patient safety
1. the bed is in the lowest position
2. the bed position is safe for the patient
- the side rails are in intending position
- the wheels are locked
antiembolic measures
1. applying anti embolic stockings
2. applying a sequential compression device (SCD)
3. high risk patients for DVT
4. complications for DVT
5. importance of proper fit
6. removal and replacement
7. thigh high versus knee high
post mortem care
1. caring for the body
2. normal body position
3. cultural specific beliefs
4. identification tags
5. autopsy = tubes remain in place
6. transport to morgue
body mechanic & patient positioning
1. positioning that maintains correct body alignment and facilitates physiologic functioning contributes to the patient's psychological & physical well being
2. back care and proper technique
key assessment points
1. skin
2. ROM
3. respiratory
types of positions
1. Fowler (sitting up) High - 90°, Low (semi) = 30°
standard = 45-60°
2. Supine or dorsal recumbent = on back
3. side-lying or lateral position = on side
4. prone position = on stomach
ROM exercises
1. active = patient can do themselves
2. passive = nurse performs for patient
Devices for good alignment, tone & to alleviate discomfort
pillows, mattresses, adjustable bed, side rails, trapeze bar, boot/shoe, floating heels
3 factors affecting ability to perform self care
1. impairment of the musculoskeletal system (weakness, ↓ ROM)
2. insufficient knowledge, limited access to facilities
3. lack of mobility or cognitive skills
before leaving patient room do these things
1. bed is in lowest position & safe for patient
2. bed controls are functioning
3. call light is functioning & w/in reach
4. side rails are raised if indicated
5. wheels are locked
4 key point associated with use of body mechanics
1. develop a habit of erect posture (correct alignment)
2. use the longest and strongest muscles of the arms and legs in strenuous activities
3. use the internal girdle & long midriff to stabilize the pelvis & to protect the abdominal viscera when stooping. contract gluteal ↓ & abdominal ↑
10 nursing interventions to prevent falls
1. complete risk assessment
2. indicate risk for falling on patients for & chart
3. keep bed in low position
4. keep wheels locked on bed & wheelchair
5. leave call bell w/in reach of patient
6. instruct patient regarding use of call bell
7. answer call bell quickly
8. leave night light on
9. eliminate all hazards (things on floor, water on floor
10. provide non-skid footwear
11. leave water, bed pan, tissues within reach
devices to promote correct alignment
1. trochanter roll = support hips & legs
2. high top shoe, foot boot or foot board = maintains dorsiflexion position