Group A: Syndia Saint Jour Jean Germain Diondra Edmonds Raya Ioffe Anjna Masih Angelo Perez Nancy Mustafa. Safety

Group A: Syndia Saint Jour Jean Germain Diondra Edmonds Raya Ioffe Anjna Masih Angelo Perez Nancy Mustafa Safety A week later, Sherri finds out that Ms Garcia grandmother is in the hospital for pneumonia. Sherri visits Ms Garcia and tells her that her grandmother is confused and keeps pulling out her IV and climbing out of the bed. The nursing staff members have tried to reorient her grandmother but she is still trying to take off her oxygen and pull out her IV. The staff members have applied wrist restraints to her grandmother. Ms Garcia is upset about this and ask Sherri why they did this. What is an appropriate response? I understand your concern, the restraints are for her safety. Her age population, her recent change of environment and the pneumonia infection has led to her to have an altered mental status (Hinkle, 2014). She is not aware of her surroundings and the care she is receiving. These restraints will prevent her from pulling out the IV, oxygen tubing and climbing out of bed. The PCA will check on her every 30 minutes and I will check on her every 1 2 hours (Arikian, 2013). We will also remove them to check her circulation and perform range of motion exercises. In a few days when the infection has resolved, we will check if it is safe to remove the restraints. A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? (Select all that apply) a) Explain the use of a call light b) Keep the bed in low lock position c) Keep all side rails up when patient is not out of bed d) Place a bedside commode near the bed e) Ensure that the pathway to the bathroom is clear f) Keep the patient s personal items (e.g book, reading glasses, watch and comb) in the bedside table

Rationale: A) Applies to all patients being oriented to a new unit B) Applies to all patients, bed must be in lowest position to prevent injury C) Unlawful use of restraint D) Patient is able to ambulate to the restroom E) This ensures safety, fall prevention F) By having belonging nearby, prevents unnecessary ambulation Care Plan NANDA nursing dx 1 Acute confusion related to hypoxia as evidenced by patient pulling out IV, removing oxygen and getting out of bed. Goal: Patient will demonstrate improved cognitive ability by time of discharge. Implementation & rationale: 4 interventions with teaching, cite rationale Evaluation: Gordon s Functional Health Care Patterns Diagnosis (List 2) Planning (outcome/goal) Measureable goal during your shift (at least 1 per diagnosis) Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale (use APA citations) Evaluation Goal Met, partially met, or not Met & Explanation Acute confusion related to hypoxia as evidenced by patient Patient will demonstrate improved cognitive ability by time of discharge Assess patient s level of conscious and if patient is oriented x3 The degree of confusion will determine the amount of reorientation and intervention the patient will need to Patient has demonstrate d improved cognitive ability.

pulling out IV, removing oxygen and getting out of bed. evaluate reality accurately. The person may be awake and aware of his or her surroundings. To provide baseline for comparison with ongoing assessment findings and to detect any improvement or decline in patient s Neurologic function

Gordon s Functional Health Care Patterns Diagnosis (List 2) Planning (outcome/goal) Measureable goal during your shift (at least 1 per diagnosis) Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale (use APA citations) Evaluation Goal Met, partially met, or not Met & Explanation Prevent further deterioration and maximize level of function: Provide calm environment; eliminate extraneous noise and stimuli. Increase level of visual and auditory stimulation can be misinterpreted by the confusion patient. Picture on walls or even shadows can be perceived by the confused patient as threatening. High noise level can disrupt sleep and add to level of anxiety and stress. (Gulanick B.J) Noise limited and environmen t kept calm during shift Communicate using simple, concrete noun in positive terms This communication technique can reduce anxiety experienced in unfamiliar surroundings. For example, asking the confused person to Stay sitting in the chair is more Communica tion kept simple and patient was less anxious during shift.

positive than saying Don t get up. (Gulanick B.J) Evaluate responses on diagnostic examinations memory loss can contribute to the person s inability to accurately respond to the environment stimuli. A common screening tool is the Mini Mental state Examination. The Confusion Assessment Method is a valid and reliable instrument that can help monitor changes in a person s cognitive Decrease attention span and function. This tool is effective when assessing older adults. (Gulanick B.J) MMSE used and cognitive level was discerned In a matter of fact manner give the client factual feedback on misperceptions, delusion, or hallucination and convey that others do not share his or her interpretation When given feedback in a nonjudgmental way, the patient can feel validated for his or her feeling, while recognizing that his /her perceptions are not shared by others. (Gulanick B.J) Feedback given and patients feelings were validated Determine family members resources and Referral of the family for often needed legal and financial guidance may be Social worker was contacted to provide

their availability and willingness to participate in the meeting the patient needs. (Teaching with rational) necessary. Community resources provide support, assist with problem solving and help the family cope with long term stress in caring for the patient. family with resources Avoid use of restraints. Obtain a physician's order if restraints are necessary Restrained elderly clients often experience an increased number of falls, possibly as a result of muscle deconditioning or loss of coordination (Tinetti, Liu, Ginter, 1992; Wilson, 1998). ). Restraint free extended care facilities were shown to have fewer residents with activities of daily living (ADLs) deficiencies and fewer residents with bowel or bladder incontinence than facilities that use restraints (Castle, Fogel, 1998). Restraints deemed necessary and physician s order was obtained.

NANDA nursing dx 2 Ineffective Airway Clearance r/t tracheal/bronchial inflammation and tenacious secretions AEB PT confusion, sputum thick yellow/green and dyspnea; RR 11. Goals: Exhibit patent airway with breath sounds clearing; absence of dyspnea. Recognize/ establish behaviors to attain airway clearance Gordon s Functional Health Care Patterns Diagnosis (List 2) Planning (outcome/goal ) Measureable goal during your shift (at least 1 per diagnosis) Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale (use APA citations) Evaluation Goal Met, partially met, or not Met & Explanation 2. Ineffective Airway Clearance r/t tracheal/bronchia l inflammation and tenacious secretions AEB PT confusion and sputum thick yellow/green and dyspnea RR 23 and labored. A. Recognize/ establish behaviors to attain airway clearance by end of shift. B. Exhibit patent airway with breath sounds clearing; absence of dyspnea within 48h.

Evaluation Gordon s Functiona l Health Care Patterns Diagnosi s (List 2) Planning (outcome/goal ) Measureable goal during your shift (at least 1 per diagnosis) Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale (use APA citations) Evaluation Goal Met, partially met, or not Met & Explanation 1 Assess the patients rate and depth of respirations and chest movement. 1 Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.(journal of Clinical nursing, 159110, 440 449). Goal Met. 1 The patient had a normal rate and depth during assessment.

heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction. (Journal of Clinical nursing, 159110, 440 449). 3 Elevate head of bed, change position frequently. 4 Teach and assist patient 3 Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of secretions. (Journal of Clinical nursing, 159110, 440 449). 4 Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage her to do so often. (Journal of Clinical nursing, Goal Met 3 The patient head of the bed was elevated, due to the elevation it helped Mrs G expectorate more of her secretions. Goal Met

with proper deep breathin g exercises. 159110, 440 449). 4 Mrs G was observed with patent airway her breath sounds are clear and absence of dyspnea and cyanosis. Journal of Clinical nursing, 159110, 440 449). Multidisciplinary Consults & Discharge Referrals Social Services referral for Dementia Specific Units Social services: are people who specialize in the delivery of direct services to individuals and families. Services that can be provided in public agencies at the federal, state and local level or in private, non profit settings. Social services can sometimes also referred to as human services they can sometimes include services oriented toward the prevention, improvement, or resolution of health, mental health, social,or environmental problems that affect individuals, families, specific groups, or communities. In this case the service would be dementia specific units. Which are alzheimer special care units who are designed to meet the specific needs of individuals with Alzheimer's disease and other dementias. Special care units can take many forms and exist within various types of residential care. Such units most often are cluster settings in which persons with dementia are grouped Psych Referral Psychiatrists: Psychiatry is a medical specialty concerned with the prevention, diagnosis, and treatment of mental illness. Psychiatrists are MDs who may also have additional training in a psychiatric subspecialty, such as geriatric psychiatry. Psychiatrists can prescribe medication, which can be effective in the management of some behavioral and psychiatric symptoms. Persons with Alzheimer's disease may experience behavioral and psychiatric symptoms that can cause personality changes and agitation. In the early stages of the disease, people may experience irritability, anxiety, or depression. In later stages, other symptoms may occur, such as sleep disturbances, physical or verbal outbursts, Homecare nurse post discharge referral Homecare nurse: provide care in the home making it possible for individuals with dementia to stay in their homes longer. Services vary from assistance with daily living activities to providing skilled nursing care. Geriatric Physician Referral Geriatric Physician: Specializes in physical illnesses and disabilities associated with old age, and in the care of older people. If the person being assessed is frail or in poor general health, they may be referred to one of these specialists to see whether their symptoms are due to a physical illness. They may have a physical illness as well as dementia.

together on a floor or a unit within a larger residential care facility. emotional distress, restlessness, delusions, or hallucinations.

References Arikian, V. P. (2013). The Basics. Kaplan Janice L. Hinkle, K. H. (2014). Brunner & Suddarth's Textbook of Medical Surgical 13th Edition. Philadelphia: Lippincott Williams & Wilkins.Reference: Gulanick B.J. & Myers, G.B. Care Plan Diagnoses: Interventions, and Outcomes. (7 th ed.), St. Louis: C.V Mosby. Phipps, W.j., Monahan, F, Sands, J.K., Neighbor, M & Marek, J.F. (2003). Medical surgical nursing: Health and Illness Perspective. (7 th ed.). St Louis C.V. Mosby Tinetti, Liu, Ginter, 1992; Wilson, (1998). Geriatric Protocols for Best Practice. Springer Publishing Company, 1999 United States. (n.d.). Retrieved March 31, 2016 from the web http://www.alz.org/eci/in_my_community_12483.asp