Which should the nurse implement when applying hot or cold therapy to prevent tissue damage?
1. Allow client to control the temperature.
2. Encourage client to reposition the source.
3. Restrict client movement from the source.
4. Apply source for 10- to 20-minute periods.
4
4. The nurse applies heat or cold therapy for 10- to 20-minute intervals to avoid tissue maceration or frostbite, respectively, and thereby prevent tissue damage. Prolonged exposure to heat or cold alters the size of regional blood vessels and alters perfusion potentially leading to tissue hypoxia, burns, maceration, bleeding, dehydration, and tissue necrosis.
1. The nurse avoids client control of the temperature because, ultimately, the nurse is responsible for the therapy.
2. The nurse instructs the client to leave the source in place to ensure the affected re-gion receives the therapy as long as it does not cause discomfort or an adverse effect.
3. The nurse ensures a client's ability to move away from the heat or cold. If the therapy becomes uncomfortable or clients experience adverse effects, clients protect themselves by moving away from the source.
You might also like to view...
The nurse is working with a patient who has been diagnosed with restless leg syndrome (RLS). The nurse recognizes this disorder may result in which symptoms or complications for the patient in the psychological domain? Select all that apply
1. Irritability and inability to concentrate 2. Disruption of bed partner's sleep 3. Inability to attend social functions due to discomfort 4. Fragmented sleep 5. Anxiety and mood changes
The nurse who had prepared the medication in the syringe has been called away to the phone and tells the
medical assistant to go ahead and give the injection to the patient. Since the patient is in a lot of pain and wants his medication right away, the best action by the medical assistant would be to immediately give him the medicine prepared by the nurse. Indicate whether the statement is true or false
The couple has had an ultrasound at 19 weeks gestation, and their fetus was found to have anencephaly. The nurse is completing counseling for the couple on the ultrasound findings. Which statement indicates that additional teaching is needed?
A. "We won't know if something is wrong until the baby's chromosomes are tested." B. "This problem is not caused by one of us having a genetic problem." C. "Our baby has an incomplete brain, and may not be born alive." D. "Waiting until our 30s did not cause this problem to develop."
A patient receiving blood begins complaining of severe chest pain and a feeling of warmth. What should the nurse do first?
a. Call the physician. b. Administer diuretics as ordered. c. Discontinue the blood transfusion. d. Assess vital signs and cardiovascular status.