Angelite Nurses

Body Mechanics

1. Safe and efficient use of appropriate muscle groups to do the job
2. Principles for the safe movement of clients
1. Keep your back straight.
2. Ensure a wide base of support (keep your feet separated).
3. Bend from the hips and knees (not the waist).
4. Use the major muscle groups (strongest).
5. Use your body weight to help push or pull.
6. Avoid twisting. (Pivot the whole body.)
7. Hold heavy objects close to your body.
8. Push or pull objects instead of lifting.
9. Ask for help as needed.
10. Synchronize efforts with client and other staff.
11. Use turning or lifting sheets as needed.
12. Use mechanical devices as needed.

Transfer and Movement Principles and Techniques

1. From bed to chair or wheelchair
1. Identify client's strongest side.
2. Place chair beside bed, on same side as client's strongest side, so it faces the foot of bed. Stabilize chair and lock wheels.
3. Lower bed, lock wheels, and elevate head of bed.
4. If assistance is needed:
1. Place one arm under client's shoulders. The other arm should be placed over and around the knees.
2. Bring legs over the side of bed while raising the client's shoulders off of the bed.
3. Dangle client and watch for signs of fainting or dizziness. (Stand in front of client for protection in case of balance problems.)
4. Protect paralyzed arm during transfer. (Use sling or clothing for support.)
5. Place client's feet flat on the floor. (If client has a weak leg, use your leg and foot to brace the weak foot and knee.)
6. Face the client and grasp firmly by placing your arms under the arm pits. Have client lean forward so that your control of the client's upper body is stabilized.
7. Using a wide base of support and bending at your knees, coach the client to assist as much as possible by using verbal instruction and counting.
8. Stand client (if weight bearing is permitted) by pivoting the feet, legs, and hips to a standing position.
9. Continue the slow pivotal movement until client is positioned over chair. Lower client into chair.
2. Log Rolling
1. Performed when spinal column must be kept straight (post-injury or surgery).
2. Two or more persons needed
1. Both staff should be on side opposite where client is to be turned.
1. One staff places hands under client's head and shoulders.
2. One staff places hands under client's hips and legs.
3. Move client as a unit toward you.
4. Cross arms over chest and place pillow between legs.
5. Raise side rail.
2. Both staff move to side of bed to which client is being turned.
1. One staff should be positioned to keep client's shoulders and hips straight.
2. One staff should be positioned to keep thighs and lower legs straight.
3. At the same time the client is drawn toward both staff in a single unified motion. The client's head, spine and legs are kept in a straight position.
3. Position with pillows for support and raise side rails.

Positioning of the Client

1. General principles
1. Privacy/draping
2. Universal precautions as needed
3. Knowledge of client's condition when moving client (e.g., paresis or paralysis of a limb; need to support joints or limbs in a specific manner; awareness of pressure points)
4. Good posture and body alignment
5. Use of added supports as needed (e.g., pillows, wedge cushions, handrolls, foot boards, etc.)
6. Comfort--reduce pressure and strain on body parts
7. Safety
8. Bed in a low position once repositioned
9. Access to personal items and care (e.g., call bell, drinking water, tissues, telephone, etc.)
10. Clients should change position fairly frequently (at least every 2 hours).
2. Positions
1. Semi-Fowler's (see Figure 3.1a)
1. Backrest elevated at 45° angle
2. Knees supported in slight flexion
3. Arms rest at sides
2. High Fowler's (see Figure 3.1b)
1. Backrest elevated at 90° angle (right angle)
2. Knees slightly flexed
3. Arms supported on pillows or bedside table
4. Allows for good chest expansion in clients with cardiac or respiratory problems
3. Supine (dorsal/horizontal recumbent)
1. Client lies on his back.
2. Client's head and shoulders slightly elevated with pillow (modified per client condition, physician order or agency policy regarding spinal injury/ surgery or post spinal anesthesia)
3. Small pillow under lumbar curvature
4. Prevent external rotation of legs with supports placed laterally to trocanters
5. Knees slightly flexed
6. Prevent footdrop with foot board, rolled pillow or high top sneakers (depends on persistence of client condition)
4. Prone (see Figure 3.2)
1. Client lies on his abdomen.
2. Head turned to one side on small pillow or on flat surface.
3. Small pillow just below diaphragm to support lumbar curve, facilitate breathing, and decrease pressure on female breasts.
4. Pillow under lower legs to reduce plantar flexion and flex knees.
5. May be modified in amputees where flexion of hips and knees may be contraindicated.
5. Trendelenburg
1. Client lies on back with head lower than rest of body.
2. Enhances circulation to the heart and brain. Sometimes used when shock is present.
3. In emergencies, the entire lower bed may be elevated on "shock blocks."
4. May be used for prolapsed cord outside of the hospital.
6. Modified Trendelenburg
1. Client is positioned with legs elevated to an angle of approximately 20°, knees straight, trunk horizontal, and head slightly elevated.
2. Used for persons in shock to improve cerebral circulation and venous return to the heart without compromising respiration. (Contraindicated when head injury is present.)
7. Lateral (side-lying)
1. Client lies on his side.
2. Pillow under head to prevent lateral neck flexion and fatigue.
3. Both arms are slightly flexed in front of the body. Pillow under the upper arm and shoulder provides support and permits easier chest expansion.
4. Pillow under upper leg and thigh prevents internal rotation and hip adduction.
5. Rolled pillow behind client's back.
8. Sims' (semiprone; see Figure 3.3)
1. Similar to lateral, but with weight supported on anterior aspects of the ilium, humerous, and clavicle.
2. Used for vaginal and rectal exams, enema administration, and drainage of oral secretions from the unconscious client. Comfortable for the client in the last trimester of pregnancy.
3. Client placed on side (left side for enema or rectal exam) with head turned to side on a pillow.
4. Lower arm is extended behind the body.
5. Upper arm flexed in front of body and supported by a pillow.
6. Upper leg is sharply flexed over pillow with the lower leg slightly bent.
9. Knee-chest (see Figure 3.4)
1. Client first lies on abdomen with head turned to one side on a pillow.
2. Arms flexed on either side of head.
3. Finally the client is assisted to flex and draw knees up to meet the chest.
4. Difficult position to be maintained--do not leave client alone. Used for rectal and vaginal exams.
10. Dorsal lithotomy (see Figure 3.5)
1. Used for female pelvic exam.
2. Have client void before assuming this position.
3. Client lies on back with the knees well flexed and separated.
4. Frequently stirrups are used. (Adjust for proper feet and lower leg support.)
5. If prolonged use of stirrups, be alert to signs of clot formation in the pelvis and lower extremities.

FIGURE 3.1a Semi-Fowler's position

FIGURE 3.1b High Fowler's position

FIGURE 3.2 Prone position

FIGURE 3.3 Sim's position

FIGURE 3.4 The knee-chest position

FIGURE 3.5 Dorsal lithotomy position

Cold Application

1. Systemic
1. Lowers metabolic rate
1. Client lies on top of one, or between two, cooling blankets. Blanket(s) are attached to a machine that circulate(s) coolant solution.
1. Follow agency policy/procedure for care of client treated with hypothermia blanket(s).
2. Monitor VS (T, P, R, and BP) regularly and frequently.
3. Attention to skin hygiene and protection with oil as required.
4. Frequent repositioning and assessment of body surface areas.
5. Observe for signs of tissue damage and frostbite (pale areas).
6. Assist client in basic needs (e.g., hygiene, elimination, nutrition, etc.).
7. Identify client temperature at which to cease the treatment (temperature may continue to drift downward). Monitor VS frequently until stable for 72 hours.
2. Alcohol or sponge bath (tepid solutions, 85°-100°F)
1. Alcohol bath--combination of alcohol and water (alcohol has a drying effect on skin--used less frequently). Alcohol increases heat loss by evaporation.
2. Sponge bath--cool or tepid (not cold) water.
3. Frequent and regular VS monitoring (T, P, R, and BP).
4. Large areas sponged at one time allowing for transfer of body heat to the cooling solution.
5. Wet cloths applied to forehead, ankles, wrists, armpits, and groin where blood circulates close to skin surface.
6. Identify temperature to cease treatment due to potential for continued downward temperature drift.
3. Discontinue systemic cold applications and report and document findings if:
1. shivering occurs (this mechanism will raise body temperature);
2. cyanosis of the lips or nails occurs; or
3. accelerated weak pulse occurs.
2. Local
1. Purposes
1. Control bleeding by constriction of blood vessels.
2. Reduce inflammation;
1. inhibit swelling;
2. decrease pain; and
3. reduce loss of motion at site of inflammation.
3. Control accumulation of fluid.
4. Reduce cellular activity (e.g., check bacterial growth in local infections).
5. Effective initial treatment after trauma (24-48 hours). This application of cold is then frequently followed by a phase of application of heat.
2. Ice caps or ice collars
1. Covered with cotton cloth, flannel, or towel to absorb moisture from condensation. Change as needed.
2. Not left on for longer than 1 hour.
3. Cease treatment and report if client complains of cold or numbness, or if area appears mottled.
3. Cold compresses
1. Use sterile technique for open wounds. Check site of application after 5-10 minutes for signs of intolerance (cyanosis, blanching, mottling, maceration, or blisters).
2. Remove after prescribed treatment period (usually 20 minutes).
3. Special considerations
1. Elderly clients and clients with impaired circulation have decreased tolerance to cold.
2. Moist application of cold penetrates better than dry application.

Application of External Heat

1. Rationale
1. Relaxes muscles in spasm.
2. Softens exudates for easy removal.
3. Hastens healing due to vasodilation.
4. Localization of infection. (Note: Do not apply heat to the abdomen with suspected appendicitis as it may precipitate rupture.)
5. Hastens suppuration.
6. Warms a body part.
7. Reduces congestion of an underlying organ.
8. Increases peristalsis.
9. Reduces pressure from accumulated fluids.
10. Comforts and relaxes.
2. Dry heat
1. Hot water bottle/bag, electric heating pad, lamp, cradle, or aquamatic pad.
2. Deeper tissue penetration modes--ultrasound, and shortwave and microwave diathermy (administered by Licensed Physical Therapist).
3. Follow agency policy for heat application mode ordered:
1. check temperature of water and machine setting carefully;
2. assess site of application frequently for signs of tissue damage or burns; and
3. be alert to potential bleeding resulting from vasodilation.
3. Moist heat
1. Soaks, compresses, hot packs
1. Follow agency policy.
2. Check temperature of application.
3. Use sterile technique for open wounds.
4. Assess skin condition after 5 minutes for increased swelling, excessive redness, blistering, maceration, pronounced pallor, or if the client reports pain or discomfort.
5. Remove the device after 15-25 minutes or as ordered/necessary.
4. Special considerations
1. Moist heat penetrates deeper than dry and is usually better tolerated.
2. The skin area involved may vary in any individual depending on the number of heat receptors present.
3. Heat is less tolerated in the very young, elderly, and clients with circulatory problems.

Asepsis

1. Defined as the absence of disease-producing organisms.
2. Medical asepsis
1. Practices to reduce the number of microorganisms after they leave the body or to reduce transmission.
2. Often referred to as clean technique.
3. Includes:
1. Hand washing
2. Universal or standard precautions
3. Isolation technique (see Unit 4)
4. Cleaning/disinfecting of equipment.
3. Surgical asepsis
1. Practices aimed at destroying pathological organisms before they enter the body through an open wound.
2. Referred to as sterile technique.
3. Includes:
1. Physical barriers--gloves, masks, gowns, drapes.
2. High risk procedures:
1. Catheter insertion
2. Surgical wound dressing changes
3. Administration of injections.
3. Associated with populations with high risk for infection. The clients in this category are:
1. Transplant recipients
2. Burns
3. Neonates
4. Immunosuppressed/AIDS, cancer clients receiving chemotherapy.
4. Principles of surgical asepsis
1. Sterile field--area where sterile materials for a sterile procedure are placed (e.g., a table covered with sterile drape).
2. Sterile field remains sterile throughout procedure.
3. Movement in and around field must not contaminate it.
4. Keep hands in front of you and above your waist (never reach across the field with unsterile items).
5. Barrier techniques (gown, gloves, masks, and drapes are used as indicated to decrease transmission).
6. Edges of sterile containers are not sterile once opened.
7. Dry field is necessary to maintain sterility of field.

Pressure Sore (Bedsore, Dermal Ulcer, Decubitis Ulcer)

1. Any lesion caused by unrelieved pressure that causes local interference with circulation and subsequent tissue damage.
2. Risk factors
1. Immobility (e.g., bed and chair-bound clients as well as those with impaired ability to reposition themselves)
2. Incontinence
3. Impaired nutritional status/intake
4. Impaired level of consciousness
5. Impaired physical condition (e.g., stability of condition, chronicity, and severity)
6. Skin condition impaired (e.g., nourishment, turgor, integrity)
7. Predisposing conditions (e.g. diabetes mellitus, neuropathy, vascular disease, anemia, cortisone therapy, etc.)
3. General prevention, care, and treatment
1. Inspect skin and document status and interventions daily.
2. Cleanse when soiling occurs (e.g., avoid hot water, harsh, or drying cleansing agents).
3. Minimize dry skin (e.g., avoid cold or dry air and use moisturizers as needed).
4. Minimize moisture from irritating substances (urine, feces, perspiration, wound drainage).
1. Cleanse immediately and apply protective barrier as indicated.
5. Avoid massage over bony prominences. (Massage around but not directly over pressure sites.)
6. Change position frequently, every 15 minutes to two hours, to decrease prolonged pressure.
7. Reduce friction and shearing (e.g., promote lifting rater than dragging).
8. Pressure reducing mattresses/beds (e.g., foam, air, gel, or water)
9. Positioning devices
10. Nutritional intake (especially calories, protein and fluids if not contraindicated). Also vitamin A and C, iron and zinc
11. ROM, ambulation, or activities as appropriate to promote increased circulation
12. Avoid pressure from appliances and care equipment.
4. Staging of pressure ulcers
1. Stage I
1. Observable pressure-related alteration of intact skin as compared to adjacent or opposite area on body
2. May include changes in color (red, blue, purple tones), temperature (warmth or coolness), skin stiffness (hardness, edema) and/or sensation (pain) (Temporary blanching from pressure can last up to 30 minutes.)
2. Stage II
1. Partial thickness loss of skin involving epidermis and/or dermis.
2. Superficial breakdown characterized by blister, abrasion, or shallow crater. Wound base is pink and moist, painful, and free from necrosis.
3. Stage III
1. Full thickness skin loss involving subcutaneous damage or necrosis. May extend to but not through underlying fascia.
2. Infection is generally present.
3. Characterized by deep crater or eschar. May include undermining and exudate. Wound base is not usually painful.
4. Stage IV
1. Full thickness loss of skin with severe destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon or joint capsule).
2. Infection, undermining, and sinus tracts are frequently present.
5. If wound contains necrotic tissue or eschar, accurate staging cannot be confirmed until wound base is visible.
5. Specific wound care treatments
1. Goals
1. Support moist wound healing.
2. Prevent or treat infection.
3. Avoid trauma of tissue and surrounding skin.
4. Comfort
2. Solutions
1. Cleansing products
2. Control of bacteria
3. Dressings or coverings
1. Damp to dry dressing (e.g., gauze dressing put on damp and removed at tacky dry status) debrides slough and eschar.
1. If dries completely and adheres to viable tissue, moisten dressing before removal.
2. Non-adherent dressing impregnated with sodium chloride to draw in wound exudate and decrease bacteria.
1. Change at least daily.
3. Transparent films, semipermeable membrane to promote moist healing by gas exchange and prevention of bacterial and fluid penetration.
1. Change when seal is lost or excessive amount of fluid collected underneath.
4. Hydrocolloid wafers contain water-loving colloids. Wound exudate mixes with wafer to form a gel, moist environment and nonsurgical debridement.
1. Wafers are occlusive and should not be used on infected wounds.
5. Gels/Hydrogels available in sheets or gels and are nonadherent. They provide a moist environment and some absorption of bacteria and exudate from the wound.
1. Not highly absorptive
1. Do not use on wounds with copious exudate.
2. Be alert to maceration of peri wound areas. (Use moisture barriers.)
6. Exudate absorptive dressings, beads, pastes, or powders which when mixed conform to the wound shape. Attracts debris, exudate, and bacteria via osmosis.
1. Removed only by irrigation. Do not use with deeply undermined wounds or tracts.
7. Foams create a moist environment and absorption.
1. Nonadherent to wound. Many require a secondary dressing to secure.
8. Calcium alginates pads or ropes made from seaweed that convert to a firm substance when mixed with exudate.
1. Highly absorptive--will dry out wounds that have little exudate.
9. Moisture barrier (e.g., A & D ointment) protects high risk skin from moisture and breakdown.
10. Skin sealant protects high risk skin from moisture and/or chemical breakdown.
4. Debridement--Removal of necrotic devitalized tissue (eschar or slough). Necrotic tissue provides nutrients for bacterial growth and needs to be removed for healing to occur.
1. Methods of debridement
1. Enzymatic
2. Mechanical
3. Surgical
4. Physiologic/autolytic
2. Be alert to bleeding and damage to adjacent viable tissue.
5. Miscellaneous
1. Whirlpool--for cleansing.
2. Hyperbaric O₂--application of high O₂ concentration for healing.
3. Electrical stimulation--stimulates healing.
4. Growth factor--cell growth stimulation.
6. Documentation
1. Interventions and response to interventions
2. Address:
1. Location of lesions.
2. Dimensions--measure and record size (length, width, and depth in cm).
1. Measuring guides with concentric circles available.
2. Use sterile applicator to determine accurate depth.
3. Photographs--need client's written permission.
3. Stage
4. Undermining, pockets, or tracts (e.g., undermining from 7:00 to 10:00 measuring 3 cm).
5. Condition of tissue
1. Granulation--red, moist, beefy.
2. Epithelialized--new pink, shiny epidermis.
3. Necrotic tissue--avascular.
1. Slough--yellow, green, gray, brown.
2. Eschar--hard, black, leathery.
6. Drainage
1. Volume (scant, small, moderate, copious, number of soaked dressings)
2. Color
3. Consistency
4. Odor
7. Periwound condition and wound margins (e.g., errythema, crepitus, induration, maceration, hematoma, desiccation, blistering, denudation, pustule, tenderness, temperature).
8. Pain--related to procedures or constant, location, severity.