Assisting a Client to the Sitting Position | 协助病人坐起 |
A partially immobilized or weak client will require nursing assistance to sit up in bed. The nurse can help such a client attain the sitting position while maintaining proper body alignment for herself and the client, Correct positioning techniques will reduce the risk of musculoskeletal injury to all persons involved. | 局部活动受限或体弱病人在床上坐起时需要护理协助。护士可以帮助病人坐起,并保持自身及病人身体的正直。正确的体位操作手法可减少所有参与者肌肉骨骼的损伤危险。 |
POTENTIAL NURSING DIAGNOSES | 可能的护理诊断 |
Client data derived during the assessment reveal defining characteristics to support the following nursing diagnoses in clients requiting this skill:
| 病人评估资料显示,病人的一些明显特征支持对需要本技术的病人所作的下列护理诊断:
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STEPS | 步骤 |
1. Wash your hands and, if appropriate, don gloves. | 1、洗手,必要时带上手套。 |
2. Put the bed in flat position with wheels on the bed locked. | 2、将床放平,锁住轮子。 |
3. Place the client in a supine position. | 3、病人处仰卧位。 |
4. Remove all pillows. | 4、拿开所有枕头。 |
5. Face the head of the bed. | 5、面向床头。 |
6. Place your feet apart with the foot nearer the bed behind the other foot. | 6、双脚开立,一腿靠床在前,另一腿稍后。 医学 全在.线提供 |
7. Ask the client to flex his knees, if possible, bringing his feet as close to his buttocks as possible. | 7、可能时要求病人屈膝,将脚尽量靠近臀部。 |
8. Instruct the client to flex his neck, tilting his chin toward his chest. | 8、让病人低头,下巴靠近胸部。 |
9. Instruct the client to assist in moving by using the trapeze bar if available or by pushing on the bed surface. | 9、让病人利用可用的横杆或按在床面上帮助移动。 |
10. If the client has limited upper-extremity strength or mobility, place his arms across his chest. | 10、如病人上肢有一点力量或有限活动力,将其双臂交叉放于胸前。 |
11. Flex your knees and hops, bringing your forearms closer to the level of the bed. | 11、屈膝下腰,前臂靠近床面。 |
12. Place your arm close to the head of the bed under the client’s shoulder and your other arm under his client’s thighs. | 12、护士靠近床头一手放于病人肩下,另一手置于股下。 |
13. Instruct the client to push with his heels and elevate his trunk while breathing out, then to move toward the head of the bed on count of 3. | 13、嘱病人脚跟撑床,抬起躯干,呼气,数到3时向床头移动。 |
14. On count of 3, rock and shift your weight from your back leg to your front leg. At the same time, the client pushes with his heels and elevates his trunk. | 14、数到3时,摆动身子,将你的体重从后腿移向前腿。同时,病人脚跟撑床抬起躯干。 |
15. Remove gloves and wash your hands. | 15、脱去手套,洗手。 |
16. Record the client's new position in nurse's notes. | 16、将病人新体位记录在护理记录上。 |
CONSIDERATIONS | 注意事项: |
The nurse must avoid dragging a client up in bed. Dragging against the bed linen causes shearing force. In addition, she should carefully observe the client for signs of development of postural hypotension (e.g., dizziness, fainting). | 护士必须避免在床上拖拉病人,在床单上拖拉会产生剪力。此外,护士还应仔细观察病人有无出现体位性低血压体症(如头晕、昏厥)。 |
CLIENT TEACHING | 病人教育: |
This skill provides an opportunity for the client and family to learn appropriate body alignment for the sitting position | 本技能为护士教育病人和家人,使其了解坐位的正确姿势提供了机会。 |