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Making an Unoccupied Bed
Assessment
1. Assess if the bed/ matress needs to be cleaned before applying clean linens
2. Assess if the client has any special needs while the bed is being changed
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Making an Unoccupied Bed
Planning
- 1. The client will have clean linens on the bed
- 2. The clean linens will be appropriate for the clients needs or condition
- 3. Linens will be changed with a minimal amount of disruption to the client
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Making an Unoccupied Bed
Supplies Needed
- fitted sheet
- flat sheet
- draw sheet
- pillowcase
- waterproof pad (if needed)
- blanket (if not on bed)
- plastic laundry bag or linen hamper
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Making an Unoccupied Bed
Procedure
- 1. Check for order or need
- 2. Gather supplies
- 3. Identify Client
- 4. Wash Hands
- 5. Assist client out of bed
- 6. Put on gloves, flatten bed, raise to workable height, lower side rail
- 7. Loosen all linens, remove call button & personal items from bed
- 8. Remove blanket & fold (put on clean surface - NOT on other bed)
- 9. Remove pillow case & set pillow on clean surface
- 10. Remove all linens - roll up - put in laundry bag
- 11. Wash matress if needed
- 12. Remove gloves & WASH HANDS
- 13. Place fitted sheet, draw sheet, & pad (if using) on first half of bed & fanfold other side
- 14. Put top sheet & blanket on first half of bed and fanfold other side
- 15. Walk to other side and put fitted sheet, draw sheet & pad on bed (be sure to remove wrinkles)
- 16. Pull top sheet & blanket over & miter corners at foot of bed
- 17. Fold blanket & topsheet over 6 inches & Fanfold blankets at end of bed
- 18. Put new pillowcase on pillow & place on bed
- 19. Put up siderail
- 20. Lower bed
- 21. Put overbed table & call button within reach
- 22. Assist client back into bed
- 23. Dispose of equipment, wash hands, document
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Making an Unoccupied Bed
Documentation
- Changing bed not normally documented -
- document any abnormalities - pus/ drainage on sheets
- docutment assessment data - client's physical status, pulse & respiratory rate before and after getting out of bed if necessary
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Making an Occupied Bed
Assessment
Chart:
- 1. Assess if client has special needs while bed is being changed (comfort needs, movement restrictions, incontinence, wound drainage)
- 2. Assess for IV lines, tubing & drains that require special precautions while moving client & changing linens
- Bedside:
- 1. Assess if bed/ matress needs to be cleaned before applying clean linens
- 2. Assess of client can assist or move self during procedure
- 3. Assess clients skin condition when rolling on side (reddened boney prominences or skin breakdown)
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Making an Occupied Bed
Planning
- 1. Client will have clean linens on bed
- 2. Clean linens will be appropriate to meet the clients needs/ condition
- 3. Linens will be changed with minimal amount of discomfort
- 4. Client will systain no injury while linens are being changed
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Changing an Occupied Bed
Implementation
- 1. Assess for orders or need, gather supplies
- 2. Wash hands, Identify client, explain procedure, PROVIDE PRIVACY
- 3. Flatten bed, raise to working height, PUT ON GLOVES
- 4. Loosen linen, remove personal items, move call device
- 5. Remove blanket & fold (place on clean surface)
- 6. Lower siderail & assist client to roll to side of bed - place pillow under head ( make sure siderail is up)
- 7. Roll soiled linens & place under client
- 8. Put bottom sheet & draw sheet on your side of bed & roll other half under soiled linens - use barrier if necessary
- 9. Raise railing on that side & go around bed - assist client to roll to other side - advise that they will roll over "lump"
- 10. Remove soiled linen & place in laundry bag
- 11. Pull clean linen from under client & tuck in
- 12. assist client to supine position & cover with top sheet
- 13. Put top sheet & blanket on bed & miter corners
- 14. Pull up on linens at clients feet to allow foot movement
- 15. Fold over top sheet & blanket 6 inches
- 16. Change pillowcase
- 17. RAISE SIDERAIL, LOWER BED
- 18. Place over the bed table & call button in easy reach of client
- 19. Dispose of equipment, remove gloves, wash hands
- 20. Document
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Changing An occupied bed
Documentation
- Changing of bed is not normally documented
- assessment should be noted if unusual
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Feeding Pump
Assessment
- Chart:
- 1. Assess fluid status - I &O
- 2. Baseline Weight
- 3. Baseline Labe Values
- 4. Bowel Movement status
- 5. Allergies
- Bedside:
- 1. Fluid status - skin turger, edema, ausc, lungs
- mucous membranes
- 2. Ausc, bowel sounds b/4 beginning & q 4-8 hrs
- 3. Allergy Band
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Feeding Pump
Planning
- 1. Client will recieve the correct volume and formula over the correct amount of time
- 2. Client's nutritional status will improve
- 3. Client's nutritional needs will be met
- 4. Client will maintain a patent airway
- 5. Client will not have diarrhea due to NG feeding
- 6. Mouth mucous membranes will remain moist and intact
- 7. Client will maintain normal fluid volume
- 8. Clien's comfort level will increase
- 9. Skin around the tibe will reamin intact
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Feeding Pump
Supplies
- 1. Tube feeding formula
- 2. Graduated container
- 3. Stethoscope
- 4. Administrations set (if not inserted)
- 5. Connector
- 6. Pump & IV Pole
- 7. Chux pad
- 8. Gloves
- 9. Irrigation set
- 10. pH strips
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Feeding Pump
Implementation
- 1. Identify Client
- 2. Provide Privacy
- 3. Explain procedure
- 4. Wash Hands & Glove
- 5. Turn off clamp on feeding tube bag
- 6. Pour tube feeding into bag
- 7. Insert drip chamber into pump
- 8. Purge Tube & insert tube into pump
- 9. Turn on Pump - clear dose & volume
- 10. Set dose - total amt in bag
- 11. Set volume - mL/ hr
- - Raise bed to working height
- - Fowlers Position
- 12. CHECK placement of feeding tube - line at nose
- 13. Insert 20 mL of air while listening over stomach
- 14. Check residual volume - note amount & color/ consistency
- 15. Check pH & replace fluids
- 16. Flush tube with 30 mL of water
- 17. Attach tubing to feeding tube
- 18. Open clamp
- 19. Press start
- - lower bed
- - raise siderail - put call button within reach
- 20. Check resudual q8h or by facility procedure
- 21. Check placement/ irrigate & check bowel sounds q4h or by facility procedure
- 22. Document
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Feeding Pump
Documentation
- Document the feeding
- - kind and amount of formula taken
- - duration of feeding
- - assessment of client
- - how you checked placement - auscultation & pH
- - Amt & color of residual contents
Record volume of feeding & water administered on clients I & O
11/5/06 1330 Aspirated 20 ml pale yellow fluid from NG tube, pH 5. Pt in Fowler's Position. 1 L room-temperature ordered formula begun @ 60 mL/ hour on pump. No nausea reported. C. Swett, STN
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Inserting Nasogastric Tube Checklist
Assessment
- 1. Assess client's level of conciousness/ ability to cooperate with procedure
- 2. Assess client's history for nasam trauma or surgery
- 3. Assess nares for size, patency have client blow nose one side at a time (listen for patency)
- 4. Assess client's comfort level (medicate if necessary)
- 5. Determine presence of gag reflex
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Inserting Nasogastric Tube
Implementation
- 1. Review client's medical record & physician's orders
- 2. Sanitize hands - Introduce self & Identify patient
- 3. Check allergy band
- 4. Provide privacy
- 5. Explain procedure & develop hand signal
- 6. Prepare the equipment - set up suction & ensure that it is working)
- 7. Place cleint in high fowler's position & lower side rail
- 8. Cover client's chest with towel & offer emesis basin
- 9. Apply Gloves
- Assessment - nasal patency & Gag reflex
- 10.Measure NG tube - mark measurement
- 11. Lubricate NG tube with water soluble lubricant
- 12. Have client hyperextend neck
- 13. Instruct client to continue to breathe during procedure
- 14. Gently insert tube into the nare until distance to estimated oropharynx distance is reached or until client begins to gag - in the event of gagging pull back one ince and pause
- 15. Have client flex neck
- 16. Instruct client to swallow sips of water while passing tube
- 17. Advance catheter forward as the client swallows intil desired length has been inserted
- 18. Secure the tube with tape or tube holder
- 19. Check for placement
- - - ascultate - 30 ml air & ascultate stomach
- - asperate - 30 ml stomach - check color & pH
- - replace stomach contents
- - Flush with 30 ml water
- 20. Secure the tube to the clients gown using safety pin
- 21. Connect NG tube to suction (if ordered)
- 23. Verbalize instructions to patient
- - notify nurse of any nausea/ vomiting
- - Reinforce that HOB cannot be lowered below 30 degrees
- -Rationale - NG tube is holding stomach sphincter open so if you lay flat, stomach contents could come up into asophagus, or go into lungs
- 24. Dispose of soiled items & put equipment away
- 25. Remove gloves & perform hand hygene
- 26. Lover bed & endure patient comfort
- 27. Place bedside table & call button within reach
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CGI- WIPE
Start with Goals
- Chart - assessment
- Gather Equipment
- Identify Client
- Wash Hands
- Identify Self
- Provide Privacy
- Explain Procedures
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Inserting NG tube
Planning
- 1. Place NG tube per Doctors Orders
- 2. Clients comfort will be maintained
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Inserting NG Tube
Supplies
- 1. NG Tube
- 2. Water-suluble lubricant
- 3. Irrigation kit
- 4. Tape
- 5. Sterile water
- 6. Cup & straw
- 7. Chux pad
- 8. Towel
- 9. Safety pin
- 10. Tongue depressor
- 11. Pen light
- 12. Emesis basin
- 13. Marking Pen
- 14. Gloves
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Inserting NG Tube
Documentation
- 1. Size and type of tube inserted (french) & placement (side of nare)
- 2. Date & time of insertion
- 3. Type of suction & pressure setting used (if ordered)
- 4. Character & amount of withdrawn stomach contents
- 5. Two methods of verification
- 6. Client assessment - vital signs
11/5/06 1030 #8 Fr feeding tube inserted without difficulty through R nare. Checked placement -ausculatated stomach, Aspirate is greeenish-brown with pH 3.5. Tube secured at nose. Pateint verbilized understning of need to not pull on tube and not lay HOB below 30 degrees. C. Swett, STN
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Bed Bath
Planning
- The client's mosedty will be preserved
- Client will not become chilled during bath
- Client will not become injured during the bathing process
- Client will feel relaxed and comfortable after bathing is complete
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Bed Bath
Assessment
- Chart:
- 1. MD restriction for activity or positioning
- 2. Personal or cultural issues regarding bathing
- 3. Assess needs for special soaps or lotions
- Bedside:
- 1. Assess client's ability to bath self
- 2. Assess any lines/ tubes that must be considered when bathing client
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Bed Bath
Supplies
- Bath Basin
- Soap
- Washclothes 2-3
- Towels 3
- Bathsheet
- Gloves
- linen bag
- hospital gown
- deodorant, powder, lotion as desired
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Bed Bath
Assessment
- 1. Identify self, Provide Privacy, Identify Client,
- 2. Wash hands
- 3. Fill basin w/ warm water & place on surfce near patient
- 4. Adjust bed to working height, lower rail
- 5. Remove blanket & fold - apply bath blanket & remove top sheet w/o exposing client
- 6. Remove gown
- 7. Put on gloves & fold washcloth - clean eyes with plain water - use different part of washcloth for each eye
- 8. Wash pace & pat dry
- 9. Lay towel under farthest arm & wash hand and arm - distal to proximal - DRY
- 10. Wash chest & dry
- 11. Place towel under close arm, wash & dry arm
- 12. Cover chest with towel, fold back bath towel, wash abdomen & Dry
- 13. Place towel under far leg - wash leg & dry
- 14. Change Water, roll patient on side - wash & dry back
- 15. Wash buttocks & dry - CHANGE WATER & WASH CLOTH
- 16. Give patient clean wash closth & allow to wash private area & dry
- 17. Put clean gown on client
- 18. Put sheet over client & remove bath sheet -MAKE SURE NO TOWELS ARE LEFT IN BED
- 19. Lower bed & raise side rail
- 20. Put soiled towels in laundry bag & clean out basin
- 21. Wash hands & document
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Bed Bath
Documentation
- Type of bath completed
- How client tolerated bath
- Note any areas of skin breakdown
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Assisting with ambulation
Planning
- Client will understand the procedure
- Client will ambulate w/o pain or injury
- Client will assist in any way possible
- Client's tubes. IV's etc will remain intact
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Assisting with ambulation
Assessment
- Chart;
- P/B history for hypotension & orthostatic hypotension
- Assess Hemoglobin - WNL - within normal limits
Bedside:
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