Homeostasis and Pain Management in the Patient with Multisystem Failure Assessment of Patient Immediately following the patient’s unresponsiveness, the nurse should check all vital signs. Airway and breathing would be a priority. This would include checking her respiratory rate, depth of respirations, and oxygen saturation level. Her confusion could have started from a decrease in oxygen supply, and if it were worsening, it would cause the unresponsiveness. Auscultating her lungs with a stethoscope for rales, rhonchi, or wheezing would give insight on a cause of heart failure and/or obstructive lung disease.
The assessment of needs forms the background or starting point for further assessments against which improvements are compared. The assessment of needs is therefore the starting point for any decisions on care strategies. Assessment of needs in Asthma Physical: when my individual’s situation had worsened due to severe asthma attacks, her parents took her to the hospital. The doctor gave her a mobilizer which helps oxygen to pass through her blood in order to relax her. To prevent future attacks and to control them the doctor taught my individual’s parents how to do first aid such as helping the person to sit upright and loosening tight clothes and ensuring that the medication is taken during an asthma attack because it helps the service user to breathe better.
The goal is to keep her pain under control if not completely relieved. Other medications (stool softeners) may be added to her drug regiment to counter act some of the side effects of Vicodin. Controlling pain will enable her to remain mobile for as long as possible, therefore promoting independence. Social isolation secondary to lack of personal involvement of sons, friends and few female family members is another concern. The nurse and the patient working in unison will develop a care plan to slowly increase the involvement of others.
2. Which assessment takes priority while the nurse provides oral care?A) Assess the sides of the oral cavity for any open sores. Feedback: INCORRECT Considering the client’s recent history of nausea and vomiting, another assessment takes priority at this time. B) Observe for excessive dryness of the mucus membranes. Feedback: CORRECT Because the client has a recent
I would ask on a scale of 1 to 10, 10 being the highest, and 1 being the lowest, how the pain feels, by communicating you can find out their pain level then inform the Nurse who will then check to see if medication can be administered. If a resident cannot communicate verbally I would monitor their body language, i.e. face expressions, i.e. holding their hand, leg or limbs, this could be their way of expressing pain or by checking their turn charts, they might of been in the same position for a long time, i.e. on the left side for some time so by repositioning the resident your relieving them from discomfort and pain.
Which nursing intervention should be initiated to prevent increased ICP? B) Administer a prescribed stool softener as needed (PRN). 4. Which medication is best for the nurse to administer to Jeff for his complaint of headache? D) Acetaminophen (Tylenol).
Fistula in the wrist is because they do usually take in this location and it reduces the risk of the patient having to go back in the hospital for more surgery. 10. Identify two ways you observed the PACU nurse act as the patient advocate A. Monitors the patient’s pain and administers appropriate medication to control patient’s pain B. Retains the patient in the PACU while monitoring the vital signs, respiratory function, blood pressure and level of consciousness to decrease the risk for injury 11.
Ethical and Nursing Sensitive Indicators When caring for any client a nurse needs to culturally aware and competent when providing care for them. Having a general awareness is a start but if a patient were to present with a cultural preference the nurse could ask the client to educate them or be proactive in teaching themselves so they can provide optimal culturally competent care. In this particular case study the client Mr. J, a retired Jewish rabbi, has been recently hospitalized after being treated for a right hip fracture after falling at home and having a diagnosis of mild dementia. A. Nursing-sensitive indicators are defined as “the structure, process and outcomes of nursing care.” These indicators help define the structure in which nursing care is given by the “supply of nursing staff, the skill level of the nursing staff, and the education/certification of nursing staff.” The goal of nursing-sensitive indicators is to provide paramount education that help improve patient outcomes on items such as falls and pressure ulcers, thus when there is greater nurse education and quality of care they are likely to be preventable or treated appropriately (American Nurses Association, 2014). In the case of Mr. J his daughter noticed a red, depressed area over Mr. J’s lower spine while the CNA was getting him out of bed.
The target areas of therapy include: eliminating oral habits (chewing gums, digit sucking and/or nail biting), decrease of unnecessary tension and pressure in the facial muscles, building muscle strength in the functioning facial structures, establish normal resting positions of the tongue, jaw, and facial muscles, and development of normal biting, chewing, swallowing, and increasing awareness of mouth and facial muscles. Children will need help and encouragement from their family and the best outcomes are achieved when parents work with their child every day. If the cause is due to an airway obstruction surgery may be needed prior to therapy. Some complication resulting from orofacial myofunctional disorders can include: speech distortion, chronic open mouth positioning, dental abnormalities (e.g. over jet and open bite), tooth decay, treatment discomfort,
The patient will be carefully exposed to their trauma. EMDR, eye movement desensitization reprocess, goal is to reduce the effect of the memory by teaching the patient certain eye movement to avoid the trauma. All three therapies are very successful coping mechanisms. Although there is no exact medication to cure post-traumatic stress disorder, there are a couple of medications that can help a patient deal with the symptoms. Antipsychotics can be used to mitigate anxiety and to avoid outbursts.