NClex 3500 Fundamentals of Nursing
Terms in this set (96)
Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing
capillaries and, eventually, resulting in necrosis) increase the risk of pressure ulcer development. They can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30
degrees.
Sets with similar terms
Which action is essential when the nurse provides a continuous enteral feeding?
Which nursing action is essential when providing continuous enteral feeding? Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines.
Which nursing action is appropriate when advancing the rate of a continuous tube feeding?
The appropriate nursing action when advancing the rate of a continuous tube feeding is to program the infusion pump at 10 to 40 mL per hour for the initial feeding. A bolus of formula is infused over 20 to 30 minutes during the initial feeding for an intermittent, not continuous, tube feeding.
When would the nurse change the equipment used for administering enteral feeding via continuous tube feeding?
The set should be changed every 24 hours or as per manufactures instructions.
What safety measures have to be maintained while the patient is receiving an enteral tube feeding?
Wear gloves when handling feeding tubes and avoid touching can tops, container openings, spikes and spike ports. Label equipment: Labels should include the patient's name and room number, the formula type and rate, the date and time of administration and the nurse's initials.