chapter 2-basic care and comfort

Basic Care and Comfort

Diana R. Mendoza MD, RNFaculty, College of Nursing

Basic Body Mechanics

• The refers to the function and muscle in the application of the mechanical principles to the activities of the patient and the nurse. The nurse can efficiently life and turn the patient when giving care without causing injury to her own body. This is also contributed with the attainment of nursing care goals.

• Nursing care goals–To permit normal functioning• Eating is usually done in sitting position

because the gravitational flow assisst the food in reaching the stomach.

–To facilitate healing–To prevent complications and

deformities–To relieve pain

Principles of Body Mechanics• The equilibrium of an object is maintained if the line of

gravity passes through it’s base support. The closer this line is to the center of the base support, the greater the stability.– Start movement with proper body alignment– Keep back straight– Stand as close as possible to the object to be moved or adjust

working area to waist level– Avoid stretching, reaching, twisting (moves line further from

center)– If possible, pull an object toward self rather than push it away

(pulling aslo creates less friction than pushing)

• The lower the center of gravity, the greater the stability–Flex knees, hip and ankle

• The wider the base support, the greater the stability–When pushing, enlarge the base of

support; move from foot forward–When pulling; move 1 foot

backward (if facing object) or forward (if facing away from object)

• Reduce friction, also to reduce force of work–Reduce surface are of object to be

moved. Example; for immobile clients, place arms on chest, use a lift sheet over a smooth, dry bed.

• Reduce the force of work–Ask for help (2 workers + load by 50%) or

use mechanical aids– Encourage the client to assist as much as

possible–Move objects along a flat or level surface,

e.g: lower nead of bed before moving a client up a bed–Use a lever, roll, turn, pivot, push or pull

instead of lifting.

• Use larger muscle groups for more forceful movements–Use the stronger gluteal and leg

muscles rather than the sacrospinal back muscles to exert an upward thrust to lift object.

• Prepare muscles using isometric contractions before moving an object to minimize atrain and stabilize the trunk.–Contract/ tighten gluteal muscles

before moving

• Coordinate movement to maximize force but minimize stem–Person with heaviest load coordinates

team, by counting to three.• Alternate periods of rest and activity

to prevent muscle fatigue

Transfer techniques

• From bed to chair/ wheelchair– Place chair at 45⁰ angle bed, on client’s stronger

side– Lower bed, elevate head of bed, and lock wheels– Assist client to sitting position; one arm under

shoulders lift off bed, other arm over and around knees bringing legs down

– Client reaches around nurse’s scapula but not around neck.

–Watch out for postural hypotension. Be in front of client in case of imbalance. Use transfer aids, e.g. belt if needed.–Wide stance, bend knees, put arms behind

their scapula– Strengthen your knees as they push off the

bed, assist to stand, pivot on their strong leg, hands on arm rest and sit.–When a client is heavy and has little ability

to bear weight, use mechanical lift or atleast 2 nurses must assist.

• Three person carry from bed to stretcher–3 nurses stand side by side facing bed,

knees slightly flexed.–With arms of lifters (1) under clients head

and shoulders (2) around hip and thighs and (3) around ankles, roll client towards chest then lift on the count of three.–On second count of three, nurses step back

and pivot towards stretcher and gently lower client unto stretcher.

Ambulation and its Assistive Devises

• Simple assisted–Walk on clients weaker side with

your arm under their arm, while other hand encircles waist.

Ambulation and its Assistive Devises

• Cane–Client holds cane on stronger side, nurse

assist weaker side; cane advanced 4-6in ahead with weak leg/ move in line with cane; stronger leg then moves past cane.– Types: a) straight cane- least stable type, b)

quad cane- has four legs, provides more stability.

–Hold cane in hand opposite to affected extremity–Advance cane and affected leg–Lean on cane when moving good leg–To go up and down stairs, step up on

good extremity, then place cane and affected extremity on step; reverse when going down. (up with the good, down with the bad)

Ambulation and its Assistive Devises

• Walkers –Walkers ahead 4-6 in weight in arms, partial

weight on weak (affected leg) if tolerated– Elbows should be flexed at 20-30⁰ angle

when standing with hand on grips– Lift and move walker forward 8-10 inches.– Nurse should stand behind patient, hold

onto gait belt at waist as needed for balance.

Ambulation and its Assistive Devises

• Tilt table – Use for weight bearing on long bones to prevent

decalcification of bones and resulting renal calculi

– Stimulates circulation to lower extremities– Use elastic stockings to prevent postural

hypotension– Blood pressure should be checked during the

procedure.

Ambulation and its Assistive Devises

• Sliding board – Used to assist patient to slide gently off the bed– Place wheelchair close to bed, lock wheels, lock

the bed.– Remove armrest from wheelchair– Powder the sliding board, place one end of

sliding board under patient’s buttocks and the other end of the surface of the wheelchair and slide accross the wheelchair.

Ambulation and its Assistive Devises

• Lift (Hoyer)–Used for patients who cannot help

themselves and are too heavy for safe lifting by others–Mechanically operated metal frame with a

sling usually made of canvass straps.

Ambulation and its Assistive Devises

• Crutches –Client supports body with hands and arms

not under axilla to prevent “crutch palsy” (radial nerve damage)–Crutches should be kept 8 to 10 inches out

to side– Elbows should be kept at 20-30⁰ angle for

correct placement of hangdrips.

• 2 point gait: use lift partial weight bearing of both legs.– Left foot and right crutch move together 4-6 in

ahead then right foot and left crutch move together ahead.

• 3 point gait: move both crutches ahead then follow- thru with body and only strong foot touches the floor-weak leg move forward to crutches using partial weight bearing, the strong foot follows. (3 point + 1)• 4 point gait: provides most balance and stability for

client but must be able to bear full weight on both legs- right crutch forward, left foot, left crutch, right foot• Swing through: weight on supported legs and crutches

1 step in front, client swings to or through crutches.

•To stand: with both crutches in 1 hand same side as weak leg, lean ahead with stronger leg under chair and weak leg extended out front, push strongest arm down on armrest and raise body to standing position.•Going upstairs: good leg 1st .•Going downstairs: bad leg 1st.

Joint movementsMovement Action Flexion Decrease angle of joint, ex. Bending elbowExtension Increasing angle of joint, ex. Straightening

elbowHyperextension Excessively increase angle of joint, ex. Bending

the head backwardAbduction Moving bone away from midlineAdduction Moving bone towards midline (“add” to body)Rotation Moving bone around its central axis

Therapeutic exersicesExercise Description RationaleActive Range of Motion (ROM)

Performed by client without assistance

Maintains mobility of joints

Passive ROM Performed by nurse without assistance from patient

Increases motion in the joint

Active-resistive ROM

Performed by patient against manula or mechanical resistance

Provision of resistance to increase muscle power; 5lbs bags/ wt may be used

Exercise Description Rationale

Active-Assistive ROM

Performed by patient with assistance of nurse

Increases motion in the joint

Isometric Performed by patient; alternate contraction and relaxation of muscle without moving joint

Maintenance of strength when joint immobilized

Complications of ImmobilityComplication Sequelae Nursing considerations

Decubitus ulcer Osteomyelitis •Frequently turn, provide skin care•Ambulate as appropriate•Use draw sheet when turning to avoid shearing force•Provide balance diet with adequate protein, vitamins and minerals•Use air mattress, flotation pads, elbow and heel pads, speepskin•Assist with use of Styker frame of Circ-O-Letric bed

Complication Sequelae Nursing considerations

Sensory input changes Confusion, disorientation

•Orient frequently•Place clock, calendar within sight.

Osteoporosis Pathological fractures , renal calculi

•Encourage weight-bearing on long bones•Provide balanced diet•Monitor estrogen therapy, if ordered.

Negative nitrogen balance

Anorexia, debilitation, weight loss

•Give high protein diet and small, frequent feeding

Hypercalcemia Impaired bone growth •Reduce calcium in diet, encourage fluids

Complication Sequelae Nursing considerations

Increase cardiac workload

Tachycardia •Use trapeze to decrease Valsava maneuver when moving in bed•Teach patient how to move without holding breath

Contractures Deformities •Frequent change position•Use pillows, trochanter rolls, foot board to promote proper body alignment

Complication Sequelae Nursing considerations

Thrombus formation Pulmonary emboli •Leg exercises, flexion, extension of toes for 5 minutes every hour•Ambulate as appropriate•Frequent change of position•Avoid using knee gatch on bed or pillows to support knee flexion•Use elastic hose•Check Homan’s sign

Complication Sequelae Nursing considerations

Orthostatic hypotension Weakness, dizziness, faintness

•Teach patient to rise from bed slowly•Increase activity gradually

Stasis of respiratory secretions

Hypostatic pneumonia •Teach the patient the importance of turning, coughing, and deep breathing•Administer postural drainage as appropriate.

Constipation Fecal impaction •Ambulate as appropriate•Increase fluid intake and fiber in diet•Insure privacy for use of bed pan or commode•Administer stool softeners, e.g: colace

Complication Sequelae Nursing considerations

Urinary stasis Urinary retention •Have patient void in normal position, if possible•Increase fluid intake•Low-calcium diet, increase acid ash residue to acidify urine and prevent formation of calcium stones.

Boredom Restlessness •Allow visitors, use of radio, television•Schedule occupational therapy

Complication Sequelae Nursing considerations

Depression Insomnia •Encourage self-care•Start with simple, gross activity before advancing to finer motor movements•Increase period of activity as rapidly as patient can tolerate•Support patient with positive feedback for effort/ accomplishement

Specific therapeutic positionsPosition FunctionSupine Avoids hip flexion, which can compress

arterial flowDorsal recumbent

Supine with knees flexed, more comfortable

Prone Promotes extension of the hip jointNot well tolerated by persons with respiratory or cardiovascular difficulties

Side lateral Allows drainage of oral secretions

Position Function Knee-chest Provides maximal visualization

of rectal areaSide with leg bent (Sim’s) Allow drainage of oral

secretionsDecrease abdominal tension

Head elevated (Fowler’s) Increase venous returnAllows maximal lung expansionHigh Fowler’s: 60-90⁰Fowler’s: 45-60⁰Semi-Fowler’s: 30-45⁰Low-Fowler’s: 15-30⁰

Modified Trendelenburg (feet elevated 20⁰, knee straight, trunk flat, and head slightly elevated)

Increases blood return to the heartUsed for shock

Position Function Head elevated and knees elevated

Increase blood return to heartRelieves pressure on lumbosacral area

Elevation of extremity Increases venous returnIncreases blood volume to extremity

Lithotomy (flat on back, thighs flexed, legs abducted)

Increases vaginal opening for examination