Goal: The patient shows no evidence of complication, such as infection, contractures, venous stasis, thrombus formation, or skin breakdown.
1. Review the medical record and the nursing plan of care to determine the type of device being used and prescribed care.
2. Perform hand hygiene. Put on PPE, as indicated.
3. Identify the patient. Explain the procedure to the patient. Assure the patient that there will be little pain after the fixation device is in place. Reinforce that the patient will be able to adjust to the device and will be able to move about with the device, allowing him or her to resume normal activities more quickly.
4. After the fixation device is in place, apply ice to the surgical site, as ordered or per facility policy. Elevate the affected body part, if appropriate.
5. Perform a pain assessment and assess for muscle spasm. Administer prescribed medications in sufficient time to allow for the full effect of the analgesic and/or muscle relaxant.
6. Administer analgesics, as ordered, before exercising or mobilizing the affected body part.
7. Perform neurovascular assessments, per facility policy or physician’s order, usually every 2 to 4 hours for 24 hours, then every 4 to 8 hours. Assess the affected body part for color, motion, sensation, edema, capillary refill, and pulses. If appropriate, compare with the unaffected side. Assess for pain not relieved by analgesics, and for burning, tingling, and numbness.
8. Close curtains around bed and close the door to the room, if possible. Place the bed at an appropriate and comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009).
9. Assess the pin site for redness, tenting of the skin, prolonged or purulent drainage, swelling, and bowing, bending, or loosening of the pins. Monitor body
temperature.
10. Perform pin site care.
a. Using sterile technique, open the applicator package and pour the cleansing agent into the sterile container.
b. Put on the sterile gloves.
c. Place the applicators into the solution.
d. Clean the pin site starting at the insertion area and working outward, away from the pin site.
e. Use each applicator once. Use a new applicator for each pin site.
11. Depending on physician order and facility policy, apply the antimicrobial ointment to pin sites and apply a dressing.
12. Place the bed in the lowest position, with the side rails up. Make sure the call bell and other necessary items are within easy reach.
13. Remove gloves and any other PPE, if used. Perform hand hygiene.
Subscribe to:
Post Comments (Atom)
0 comments:
Post a Comment