Hazards and Interventions Group Activity
Hazard
Intervention
ROM q2-8 hrs. Can be integrated with other tasks.
Change of position side to side- q2hrs.
Teach use of incentive spirometer
Teach coughing and deep breathing- q1-2 hrs
Assess lung sounds q 2 hrs with position change.
Assess for S/S of pneumonia- productive cough, green
yellow sputum, fever, pain, crackles, wheezes and dyspnea.
Check B/P before OOB transfer. Slow position changes . Sit
on side of bed before standing. Watch for dizziness rising
from supine to standing position. May faint- get back to
chair or bed.
Holding breath. Puts great strain on heart. When moving up
in bed have patient exhale with movement.
Usually on anti-coagulants- eg ASA, Lovenox, Look for S/S of
Bleeding- in Stools guaiac (Hidden blood) bleeding gums. To
prevent have patient pump lower extremities and
apply stockings or sequential compression devices. If DVT
expected- assess for swelling, tenderness and warmth. Do
not palpate or massage. Call MD. Look under covers to
assess legs always. Check peripheral pulses.
Decreased peristalsis. Distended abdomen decreasedincreased bowel sounds. Decreased appetite- nausea and
vomiting. May present as diarrhea. Encourage 2000-3000 mL
of fluid q 24 hrs- encourage bulk- fluids, veggies if allowed.
May need stool softener, cathartic, enema. Measure calf
circumference.
Change position q 2 hrs. Positions- supine, lateral, prone,
sims, fowlers. Look for pressure points.
Ankle flexion and contraction- foot board with supine
position. Check heels for skin breakdown.
Even if no IV’s nurse is always responsible to observe for
adequate intake and output. No MD orders. Also check for
frequency of BM.
Check to see if they know person, place , and time.
Look for depression and/or sensory deprivation.
Assess for resting heart rate increase.
Monitor oral food intake for 24 hrs.