This response utilizes principles of therapeutic communication. It is an open-ended question designed to allow Mr. Matthew to verbalize any concerns about hospitalization that might be contributing to his anxiety.
This action will reduce the client’s anxiety by including the spouse, and orienting them both to the room.
Mr. Matthew’s limited activities support this nursing diagnosis. Improving mobility is a nursing priority to prevent the many potential complications.
This is a correctly stated goal. The client is always the subject of the goal, and the action is always measurable. This goal includes what Mr. Matthew is to achieve and sets a realistic deadline.
This action stimulates circulation by contracting calf muscles, which increases the venous return of blood to the heart. This decreases pooling of blood in the legs, which helps prevent venous thrombosis in the legs
This represents a complete documentation, which includes the content taught and a statement of the client’s understanding after the teaching.
This finding is a warning sign of possible thrombophlebitis and should be reported to the healthcare provider.
This method provides a slight elevation of the lower legs for comfort, but avoids pressure behind the knees which would adversely decrease venous return and decrease the risk for venous thrombosis.
The choice of this diagnosis is supported by the evidence of his BMI, which is below 18.5, placing him in the underweight category, and his lack of intake of nutrients.
Calcium must be deposited in the bone to increase bone density.
These are nutrient-rich choices. Milk is a primary source of calcium to prevent osteoporosis. The milk and oatmeal provide protein. The orange provides vitamin C. Added benefits are vitamin A from the orange and fiber from the oatmeal and the orange.
Placing the chair at a 45-degree angle on Mr. Matthew’s stronger left side provides for a safe transfer because it allows him to pivot easily from the bed into the chair.
This is the priority nursing action to prevent injury to the client and the nurse. Lowering Mr. Matthew to the floor should be done when he cannot support his own weight.
Postural hypotension can occur when the client has been lying or sitting for a prolonged period and quickly rises to an erect position. The systolic blood pressure must drop a minimum of 20 points to be considered postural hypotension.
Deep breathing can help prevent atelectasis, which can lead to pneumonia.
Mr. Matthew has not demonstrated the correct technique. The nurse should help him place his hands on his abdomen above the belly button and instruct him to try to breathe in and make his hands go up. This method is generally effective in teaching the client deep-breathing by using the diaphragm (abdominal breathing) to expand the lungs.
The Braden Scale assesses many risk factors that may contribute to pressure sores. Assessed are nutrition, the ability to move, the degree of activity, moisture on the skin, sensory perception, and friction and shear. A lower score indicates a higher risk for pressure sores.
The client should be repositioned every two hours. The 60-degree angle for the lateral position provides comfort without placing excessive pressure on the greater trochanter.
This action should be taken first, since this is the initial dose of a new medication. It is important to verify any allergies. Clients sometimes recall additional allergies after the initial admission history has been taken.
The friendly flora in buttermilk and active culture yogurt will help maintain or restore the normal intestinal flora, helping to reduce the incidence of diarrhea or a fungal superinfection.
These active isometric exercises strengthen the large muscles of the buttocks and thighs to help prevent muscle atrophy.
The UAP should only assist by helping to bathe Mr. Matthew’s back and feet. It is best if Mr. Matthew can do the majority of the bath on his own. This will provide him with a sense of independence, as well as the exercise to help prevent muscle atrophy.
A bedside commode not only allows Mr. Matthew some independence, but it also allows him to be in the correct sitting position to promote bowel action.
These foods are rich in fiber and help promote bowel function.
This validates Mr. Matthew’s spiritual being.
This action alerts the staff of the need to respect Mr. Matthew’s quiet time.
Mr. Matthew indicates that he has faith and that this is an opportunity for him to grow spiritually.