- Maintaining Tissue Integrity
- Assess skin frequently, especially areas with high potential for breakdown
- Frequent turning; use turning schedule
- Careful positioning in correct body alignment
- Passive ROM
- Use of splints, foam boots, trochanter rolls, and specialty beds as needed
- Clean eyes with cotton balls moistened with saline
- Use artificial tears as prescribed
- Measures to protect eyes; use eye patches cautiously as the cornea may contact patch
- Frequent oral care
- Maintaining fluid status
- Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O.
- Administer IVs, tube feedings, and fluids via feeding tube as required— monitor
ordered rate of IV fluids carefully.
- Maintaining body temperature
- Adjust environment and cover patient appropriately.
- If temperature is elevated, use minimum amount of bedding, administer
acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to
blow over patient to increase cooling.
- Monitor temperature frequently and use measures to prevent shivering.
- Promoting Bowel and Bladder Function
- Assess for urinary retention and urinary incontinence
- May require indwelling or intermittent catherization
- Bladder-training program
- Assess for abdominal distention, potential constipation, and bowel incontinence
- Monitor bowel movements
- Promote elimination with stool softeners, glycerin suppositories, or enemas as
indicated
- Diarrhea may result from infection, medications, or hyperosmolar fluids