Question

1. Identify the nursing assessment needed prior to ambulating clients.

2. Identify the general best practices for safe patient handling (SPH).

3. Identify the priority nursing measures used to prevent common complications of immobility on the various body systems.

Answer 1

1

• ,Assess the general health status of the patient.
• Assess the activity tolerance,strength,coordination,baseline vital signs,balance to determine type of assistance needed,environment. ,orientation,readiness,pain.

2

Review the patients mobility status before lifting or moving them.SPH equipment use is based on the patients mobility,not the patients weight.if a patient needs more than standby assistance with moving SPH equipment is used.Eliminate or reduce manual lifting and moving of patients whenever possible.Use SPH equipment when available andthe patient until patient no longer needs the equipment.Equipment be appropriate for the activity.All SPH equipment is patient dedicated.The equipment stays with the patient until patient no longer needs the equipment.it is advisable to help patients as much as possible by gibving clear ,simple instructions with adequate time for response.Use uprigh,neutral working postures and proper body mechanics while shifting.

3 The common complications caused by immobilization are pressure injuries ,pneumonia,bone loss and loss of function in the immobilized part.

Nursing interventions to prevent respiratory complications are

• Perform respiratory assessment and vital signs check at each shift.
• Instruct patient to turn ,cough,deep-breathe every 1-2 hours.
• Instruct in the use of incentive spirometry 10 times every 1 hour.

Gastrointestinal complications

• GI assessment at each shift.
• Check daily weights and administer stool softeners.
• Monitor laboratory test results for abnormalities
• Assess patients food intake for proper nutrients,encourage extra fluids and fiber if not contraindicated.

Cardiovascular

• Perform cardiovascular assessment and vital signs at each shift.
• Encourage patient to perform active or passive range-of-motion excercises and isometric excercise if not contraindicated.

Musculoskeletal

• Perform musculoskeletal assessment at each shift.
• Active and passive ROM ecercises
• Administer calcium supplements as ordered.
• Report new abnormal findings to phyician.

Urinary complicationns

• Keep accurate record for intake and output.
• Monitor for reports of pain with urination
• Encourage increased fluid intake.
• Encourage change of position.