Nursing Interventions And Rationales

Mechanical injury to skin and tissues (strain, friction, or shear) is commonly associated with exterior devices. 10. For shoppers with restricted mobility, use a risk assessment device to systematically assess immobility-related threat components. 11. Implement a written therapy plan for topical remedy of the skin impairment site. 12. Identify a plan for debridement if necrotic tissue (eschar or slough) is current and if in line with overall client management goals. 13. Choose a topical therapy that maintains a moist wound-healing environment that is balanced with the necessity to absorb exudate and fill dead house. 14. Do not position consumer on site of impaired tissue integrity. If in line with total shopper administration objectives, 우리카지노 flip and place client a minimum of every 2 hours, and punctiliously switch shopper to avoid hostile effects of exterior mechanical forces (stress, friction, and shear). Evaluate to be used of specialty mattresses, beds, or units as applicable (Fleck, 2001). If the objective of care is to maintain the consumer (e.g., a terminally ill shopper) comfy, turning and repositioning may not be applicable. 15. Avoid massaging around site of impaired tissue integrity and over bony prominences. 16. Assess shopper's nutritional status; refer for a nutritional consultation and/or institute dietary supplements. 1. Instruct and help shopper and caregivers with removing or controlling impediments to wound healing (e.g., administration of underlying disease, enchancment in method to shopper positioning, improved nutrition). 2. Initiate a consultation in a case task with a wound, ostomy, continence nurse (WOC nurse) to establish a complete plan as quickly as doable. 1. Teach skin and wound evaluation and methods to monitor for indicators and signs of infection, complications, and healing. 2. Teach use of a topical remedy that's matched to consumer, wound, and setting. 3. If in step with total consumer management goals, teach how to turn and reposition consumer a minimum of every 2 hours. 4. Train use of pillows, foam wedges, and stress-lowering devices to forestall stress injury.



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