chapter 47 clinical application questions
Ms. Cavallo, 97 years of age, has been a resident at the rehabilitation unit for 6 weeks. She has been receiving rehabilitation therapy following the repair of her hip fractured left hip. The nursing assistive personnel (NAP) tells you that Mrs. Cavallo has not been finishing her meals over the past 2 days because of poor appetite. As you enter her room today she states, “Go away. I’m tired of all this, and I just want to stay in bed today.” You explore why she feels this way. You discover that she is unsure how to use her walker and feels safer in bed. She states, “I’m still afraid that I’m going to fall because I keep forgetting how to use my walker, and I can’t fall if I stay in bed, right?”
1. On the basis of these data, you develop a nursing diagnosis of deficient knowledge (use of walker and effects of immobility) related to lack of recall. Identify one goal, two expected outcomes, and three related nursing interventions with rationales that will help her meet the identified goal and outcomes. Goal: Patient will effectively use walker by end of two weeks.
Outcomes: Patient will be able to walk with walker with staff assistance; Patient will be able to go from sitting position to standing with walker without fear of falling.
Nursing Interventions: Patient will with therapy to effectively walk with walker. This will help the patient learn how to properly ambulate with walker.
Patient will ambulate with assist x1. They will help the patient be more confident because she will have support if she feels she is falling.
Patient will learn the effects of being immobile. This will help the patient understand the seriousness of not getting and walking.
2. You finish teaching Mrs. Cavallo about the hazards of immobility, and you begin your morning assessment. As you are assessing her skin, you notice 2-cm (0.79) redden area on her coccyx. The skin is intact, and you find no other redden areas anywhere else.
A. How would you document this finding? Redden 2-cm
1. On the basis of these data, you develop a nursing diagnosis of deficient knowledge (use of walker and effects of immobility) related to lack of recall. Identify one goal, two expected outcomes, and three related nursing interventions with rationales that will help her meet the identified goal and outcomes. Goal: Patient will effectively use walker by end of two weeks.
Outcomes: Patient will be able to walk with walker with staff assistance; Patient will be able to go from sitting position to standing with walker without fear of falling.
Nursing Interventions: Patient will with therapy to effectively walk with walker. This will help the patient learn how to properly ambulate with walker.
Patient will ambulate with assist x1. They will help the patient be more confident because she will have support if she feels she is falling.
Patient will learn the effects of being immobile. This will help the patient understand the seriousness of not getting and walking.
2. You finish teaching Mrs. Cavallo about the hazards of immobility, and you begin your morning assessment. As you are assessing her skin, you notice 2-cm (0.79) redden area on her coccyx. The skin is intact, and you find no other redden areas anywhere else.
A. How would you document this finding? Redden 2-cm