Jebrenth Apple M.

Bon
COA RLE section C

Nursing interventions for fall preventions

 For patients at risk for falls, provide signs or secure a wristband identification to
remind healthcare providers to implement fall precaution behaviors.
 Transfer the patient to a room near the nurses’ station.
 Move items used by the patient within easy reach, such as call light, urinal,
water, and telephone.
 Respond to call light as soon as possible.
 See to it that the beds are at the lowest possible position. If needed, set the
patient’s sleeping surface as adjacent to the floor as possible.
 Use side rails on beds, as needed. For beds with split side rails, leave at least
one of the rails at the foot of the bed down.
 Avoid the use of restraints to reduce falls.
 Guarantee appropriate room lighting, especially during the night.
 Encourage the patient to don shoes or slippers with nonskid soles when walking.
 Familiarize the patient to the layout of the room. Limit rearranging the furniture in
the room.
 Provide heavy furniture that will not tip over when used as support when patient
is ambulating. Make the primary path clear and as straight as possible. Avoid
clutter on the floor surface.
 Provide the patient with chair that has firm seat and arms on both sides.
Consider locked wheels as appropriate.
 Teach client how to safely ambulate at home, including using safety measures
such as handrails in bathroom.

Nursing interventions for pressure ulcer

 Determine the client’s age and general condition of the skin.
 Assess the client’s nutritional status, including weight, weight loss, and serum
albumin levels, if indicated.
 Assess for a history of preexisting chronic diseases (e.g., diabetes mellitus,
acquired immune deficiency syndrome, guillain-barré syndrome, peripheral
and/or cardiovascular disease).
 Assess the skin on admission and daily for an increasing number of risk factors.
 Assess the client’s awareness of the sensation of pressure.
 Assess client’s ability to move (shift weight while sitting, turn over in bed, move
from the bed to a chair).
 Assess for environmental moisture (excessive perspiration, high humidity, wound
drainage).
 Assess the surface that the clients spend a majority of time on (mattress for
bedridden clients, cushion for clients in wheelchairs).
 Assess the skin over bony prominences (sacrum, trochanters, scapulae, elbows,
heels, inner and outer malleolus, inner and outer knees, back of the head).
 Use an objective tool for pressure ulcer risk assessment: Braden scale, Norton
scale.
 Measure the size of the ulcer, and note the presence of undermining.
 Assess the condition of wound edges and surrounding tissue.
 Assess ulcer healing, using a pressure ulcer scale for healing (PUSH) tool.
 Apply a flexible hydrocolloid dressing (e.g., Duoderm) or a vapor-permeable
membrane dressing (Tegaderm).
 Apply a vitamin-enriched emollient to the skin every shift.
 Apply Hydrogels (Carrasyn V, Aqua Skin)