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Physical Assessment Inspect all external structures for signs of: -inflammation -drainage -encrustations -other abnormalities
moisten with sterile water or normal saline over the lid margins.
2. Wipe the loosened secretions from the inner canthus of the eye to the outer canthus.
Eyeglass Care
Purpose: To prevent breaking or scratching the lenses.
1.Glass lenses can be clean with warm water and dried with a soft tissue that will not scratch the lenses.
3. Assess clients physical ability to help with moving and positioning. a. Age b. Level of consciousness and mental status c. Disease Process
and Coordination
e. ROM
4. Assess physicians orders. Clarify whether any positions are contraindicated because of clients condition.
bed to comfortable to comfortable working height, and get extra help if needed
7. Explain the procedure to the client. 8. If tolerated, position client flat in bed 9. On count of three, rock another before changing to and shift weight from front orback leg at thesame time to moving the client. position
Client pushes with heels and elevates trunk.
Before flattening the bed of patient, account for all tubing, drains and equipment to prevent dislodgement.
3.Place feet apart with foot nearest head of bed behind other foot (forward backward stance) 4. When possible, ask client to flex knees with feet flat on bed.
7. Flex knees and hips, bringing forearm closer to the level of bed. 8. Instruct client to push with heels and elevate trunk while breathing out. 9. On count of three, rock and shift weight from front to back leg at the same time Client pushes with heels and elevates trunk.
3. Begin at clients feet. Face foot of bed at 45 degree angle. Place feet apart with foot nearest head of bed behind other foot (forward backward stance) Flex knees and hips as needed to bring arms level with clients legs Shift weight from front to back leg and slide clients head diagonally toward head of bed.
4. Move parallel to clients hips. Flex knees and hips as needed to bring arms level with Clients hips. 5. Slide clients hips diagonally toward head of bed.
6. Move parallel to clients head and shoulders. Flex knees and hips as needed to bring arms level with the clients body.
7. Slide arm closest to head of bed under clients neck with hand reaching under and supporting clients opposite shoulder 8. Place other arm under clients back. 9. Slide clients trunk, shoulders, head and neck diagonally toward head of bed.
10. Elevate side rail, move to other side of bed and lower side rail.
Moving immobile client up in bed with draw sheet or pull sheet (two nurses)
1. Place draw sheet, or pull sheet under client by turning side to side. Have sheet extend from shoulders to thighs. Return client from supine position. 2. Position one nurse at each side of client.
3. Grasp draw sheet firmly near the client 4. Place feet apart with forward backward stance. Flex knees and hips. Shift weight from to back leg and move client and draw sheet.
2. Position client to side of bed. 3.Prepare to turn client unto side. Flex clients knee that will not be next to mattress. Place one hand on clients hip and one hand on clients shoulder. 4. Roll client unto side toward you. 5. Place pillow under clients head and neck.
6. Bring shoulder blade forward. 7. Position both arms in slightly flexed position. Upper arm is supported by pillow level with shoulder, other arm by mattress. 8. Place tuck-back pillow behind clients back.
9. Place pillow under semi-flexed upper leg level at hip from groin to foot. 10 Place sandbag parallel to plantar surface of dependent foot.
1.With client supine, roll client over arm positioned close to body, with elbow straight And hand under hip. Position on abdomen in center of bed.
2. T urn client to one side and support head with pillow. 3. Place small pillow under clients abdomen below level of diaphragm.
4. Support arms in flexed position level at shoulders. 5. Support lower legs with pillows to elevate toes.