What interventions are needed to reduce the possibility of shear?
What will be an ideal response?
• Unless contraindicated, the head of the bed should be kept at the lowest degree of elevation.
General recommendation is at or below 30 degrees.
• If the head of the bed needs to be elevated (e.g., during oral intake), limit the elevation time.
• When the head of the bed is elevated, use the knee gatch to ensure the knees are elevated. This
will help keep the torso from sliding down in the bed.
You might also like to view...
The nurse is caring for a child with rheumatoid arthritis. Which is an appropriate nonpharmacologic measure to reduce the joint pain associated this disease?
1. Elevation of the extremity 2. Immobilization 3. Massage 4. Application of moist heat
The nurse explains to a 43-year-old patient with a benign tumor in her right breast that a benign tumor differs from a malignant tumor in that benign tumors:
a. do not cause damage to adjacent tissue. b. are simply an overgrowth of normal cells. c. do not spread to other tissues and organs. d. frequently recur in the same site.
Which outcome reflects the goals of Virginia Satir's Communication Theory? Family communication is:
a. complementary b. without conflicts c. clear, accurate, and meaningful d. stabilized
Which statement about skin tears is correct?
a. Skin tears only occur during bathing. b. Skin tears are not usually painful. c. Infection can develop in a skin tear. d. Skin tears usually occur over a bony area.