During the secondary survey it is discovered that a trauma patient has pelvic instability. Which nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Recheck stability every hour.
2. Monitor for bleeding.
3. Assist with wrapping a sheet around the pelvis.
4. Turn the patient every 2 hours, alternating sides and back.
5. Place the patient in high Fowler's position.
2,3
Rationale 1: Once pelvic instability is confirmed, no further stability checks are indicated.
Rationale 2: An unstable pelvis may cause damage to internal structures and bleeding. Urine should be monitored as well as skin color, skin temperature, and vital signs.
Rationale 3: A sheet can be wrapped around the pelvis to help stabilize it until further treatment is performed.
Rationale 4: An unstable pelvis can cause internal damage. The patient should not be turned until the pelvis is stabilized.
Rationale 5: High Fowler's position will place pressure on the unstable pelvis. The patient should be supine.
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