concepts mobility hesi case study
As part of the admission interview the nurse asks mr matthew and his wife how they would like to be addressed by the staff
what concerns do you have about being hospitalized
Mr matthew says my sweatheart and i have never been apart
explain the room environment to him
Mr. Matthew state the pain level is 8 out of 10 in foot etc.
impaired physical mobility
in developing a plan of care the nurse consults with mr. matthew to identify a short term goal
the client will sit in the chair for each meal beginning on the day of admission
which instructions should the nurse convey to help prevent venous thromboembolism?
teach him to flex his feet in bed
explain enoxaparin(Lovenox injections will be administered routinely
how should the nurse document teaching?
dorsal and plantar flexion demonstrated to client and returned correctly stated he will perform 10 times an hour
which assessment reflects possible DVT
unilateral calf edema
positive homans sign
mr matthews BMI is 18.
imbalanced nutrition:less than body requirements
which foods are to prevent a decrease in bone density?
calcium rich foods
which foods should the nurse encourage?
milk oatmeal and an orange
right leg weakness in a hospital bed
position the chair at a 45 degree on mr matthews left side
he feels faint and is 5 feet from the bed
priority is to lower mr matthew to the floor
how should the nurse explain this dizziness to the client?
you probably experienced postural hypotension let me explain
he has fine crackles while breathing and is at risk for pneumonia.
teach him to take ten deep breaths an hour while awake.
mr matthew is raising his shoulders while he is breathing.
help the client perform the correct technique for DEEP breathing .
The braden scale is for:
risk for pressure sores
He is at risk for pressure sores. what should the nurse do?
reposition mr matthew in bed from supine to 60 degree side lying position every two hours.
The healthcare provider prescribed an oral antibiotic for mr matthew on admission to the hospital to treat the ulcer on his right foot
1st thing is to ask about allergies
during the course of antibiotics he should what?
add buttermilk or active culture yogurt to the diet daily
mr matthew has stayed in bed for a weak and the nurse is worried about muscle atrophy.
teach mr matthew to perform exercises such as gluteal sets and quadriceps sets 5 times every 2 hours while awake.
In planning morning care for mr matthew what action should the nurse take?
ask the UAP to assist mr matthew in taking a complete bed bath
mr matthew is concerned that he may become constipated due to his lack of activity and poor diet
offer to obtain a bedside commode for mr matthew
a dietary plan to help this would include:
increase vegetables fresh fruit and dried fruits
the nurse notices a bible in the mr matthew room. While talking to him the nurse senses a serenity about him
i sense a spiritual strength about you
what should the nurse do to provide for mr matthews spiritual needs?
place a sign on the door to allow mr matthew some quiet time in the morning.
mr matthew says he has faith that God will be with him through this challenge to regain his health
readiness for enhanced spiritual well being