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Zorluk: Çok zorBasic Care and Comfort

A nurse is preparing to transfer a client with left-sided hemiplegia and a history of orthostatic hypotension from the bed to a wheelchair. Arrange the following nursing actions in the correct chronological sequence.

  1. 1Place the wheelchair on the client's right side at a 45-degree angle and lock the wheels.
  2. 2Assist the client to sit on the edge of the bed and assess for reports of dizziness.
  3. 3Apply a transfer belt securely around the client's waist.
  4. 4Brace the client's left knee and foot with your own knee and foot.
  5. 5Instruct the client to bear weight on their right leg and pivot into the wheelchair.

Cevap

The correct sequence is to first position the wheelchair on the client's strong side, sit the client up to assess for orthostatic hypotension, apply the transfer belt, brace the weak knee during standing, and finally have the client pivot on their strong leg.
The correct chronological sequence prioritizes environmental preparation, physiological safety, and proper body mechanics. First, the wheelchair must be locked on the client's strong (right) side to ensure the environment is ready. Second, the client must dangle on the edge of the bed to allow their blood pressure to adapt, preventing syncope related to their history of orthostatic hypotension. Third, a transfer belt is applied to ensure a safe hold. Fourth, as the client stands, the nurse must block the affected (left) knee to prevent buckling. Finally, the client uses their strong (right) leg to bear weight and safely pivot into the wheelchair.

Adım Adım Çözüm

1
Place the wheelchair on the client's right side at a 45-degree angle and lock the wheels.
The environment is safely prepared before the client is moved.
Preparing the equipment first prevents leaving the client unattended. The wheelchair must be on the unaffected (right) side so the client can pivot toward their strong side.
2
Assist the client to sit on the edge of the bed and assess for reports of dizziness.
The client is moved to an upright position and assessed for syncope.
Because of the history of orthostatic hypotension, the client must dangle at the bedside to allow blood pressure to stabilize before further activity.
3
Apply a transfer belt securely around the client's waist.
The nurse has a secure gripping point for the transfer.
A transfer belt prevents falls and avoids unsafe lifting methods, such as pulling on the client's arms or shoulders.
4
Brace the client's left knee and foot with your own knee and foot.
The client's paralyzed leg is stabilized.
Blocking the affected (left) knee prevents it from collapsing or buckling when the client attempts to bear weight.
5
Instruct the client to bear weight on their right leg and pivot into the wheelchair.
The client safely completes the transfer into the wheelchair.
The client uses their intact strength on the right side to pivot and lower themselves safely into the chair.

Anahtar Kavram

Safe transfer techniques for hemiplegia and orthostatic hypotension
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Konular

Basic Care and Comfort

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