Question

5)    With reference to the previous question, what are the actual/potential nursing care needs of your client? (in 30-40 words each).

Care needs

5.1)     Mobility and transfers

5.2)     Elimination needs

5.3)     Comfort and sleep

5.4)     Nutrition needs

5.5)     Oral hygiene

5.6)     Personal hygiene and grooming

5.7)     Falls prevention

5.8)     Pressure injury prevention

5.9)     Prevention of deconditioning

Answer 1

5.1 Answer.

Nursing care for mobility and transfer ......

First of all nurses need to understand the level of mobility impairment the client has ,

Certain degree of impairment mobility can either be recurring or permanent , some mild degree of movement impairment is common in client with fracture , Stoke and other movement disorders such as multiple sclerosis etc,

Mobility :

1. Assist the client in daily living activities such as bathing , brushing .

2. Assist client to the washroom if mobility is impaired more then normal level.

3. Assist client in active and passive exercises.

4. Help client standing with support.

5. Instruct client to move his limbs with support for proper circulation.

Patient with permanent movement disability are sent to rehabilitation center and even get discharge from hospital earlier.

Transferring patient .

1. Explain client what you are going to do and why you are doing so.

2. While transferring client put the wheel chair close to bed.

3. Lock the wheel chair so it don't move unnecessarily and it also provides grip .

4. provide sufficient time to client for being ready.

5. Nurses should maintain proper body alignment while moving and transferring client,in order to distribute weight equally .

6. Only one staff is not sufficient to move the client ,atleast 2 staff member are needed.

7. Maintain patient safety while transferring.

8. Do not force client to move his limbs forcefully if he can't do so.

5.2 Elimination need

It is the basic body functions of every individual, people usually carry out in private without discussing in public because of embarrassment.

Nurses role.

1. Ask client about his bowel elimination.

2. Make sure that the client maintains normal bowel pattern .

3. Nurses should encourage client to discuss if difficulty is occuring .

4. Encourage client to discuss if he has diarrhoea, constipation, fecal incontinence etc.

5. Nurses responsibility is to manage bowel elimination by providing proper care to the patient according to condition such as, enema in constipation, antidiarrheal drug or fluid in diarrhoea,

Etc.

5.3 comfort and sleep.

Sleep is a vital activity that is very important for normal functioning of individual, nurses should make sure that patient gets proper rest and sleep ,

1. Encourage client to do some physical activites such as exercise, walking or other recreational activities.

2. Tell client to avoide sleeping in day time.

3.Make sure patient do notake large meal before bed.

4. Give sleep medications as prescribed.

5. Make the room dark while turning off lights.

6. Close the door to avoid noise if any and keep your room quiet.

7. Encourage client to Perform deep breathing exercises.

8. Encourage client to think something positive or good.

5.4 Nutritional needs

Taking proper meal in a balanced way is very helpful for maintaining a healthy life and recovery from diseases early, while taking care of client make sure he takes good amount of food it also depends upon clients condition what kind of food is to be given in which disease condition.

1. If a patient is diabetic he will be provided with diabetic diet which is free from sugar and carbohydrates , patient should be encouraged to take green leafy vegetables, sprouts, egg , etc.

2. If a patient is having hypertension then DASH(dietary approach to stop hypertension) diet is given to the patient that has less pottasium ,

3. Patient has fracture then calcium rich diet is recommended.

She should know about the type of diet and condition in which that can be given.

5.5 oral hygiene.

The main aim of maintaining oral hygiene is to keep the mucosa, mouth and lips soft , and also by removing food debris from brushing reduces the growth of microbes which causes tooth dacay and foul smell.

Nurses role.

1. check patients movement level.

2. If the patient is unable to get out from the bed make sure patient mouth is clean, if the patient cannot brush by himself perform oral care by using oral hygiene techniques.

3. integration can sit on the bed but annot move out of the bed ,provide articles on the bed and a assist in cleaning his mouth and maintaining oral hygiene.

4. Provide oral hygiene to the bedridden patient every 8 hourly.

5. Assist patient in maintaining oral hygiene by providing the article such as toothbrush ,toothpaste, tissue paper ,water bowl, basin etc .

6. make sure patient do not choke while giving mouth care to the bedridden patient.

5.6 personal hygiene and grooming

Personal hygiene and grooming boosts self confidence of individual , and also helps in adjusting with the society,

Nurses role.

1. Provide bed bath to the bedridden client.

2. Provide clean clothes every day to the patient.

3. Change bed linen and towel every day.

4. Comb the hair of client if he can't do by him/ her self.

5. Apply emolient and lotion to the skin.

6. Maintain hygiene around the patient environment.

5.7 Fall prevention.

Falling from the bed can occur any time if support is not provided to the client, semi-conscious client and client with mental disorders, geriatric client , pediatrics client are at the higher risk for fall,

Nurses role.

1.Lock ide rail every time.

2. Instruct client to ring bell when needed.

3. Instruct client not to move from the bed without informing to the nurse.

4. Side rail should be always locked for semiconcious client and geriatric client .

5. For paediatric client mother is advised to stay with child.

6. Ask client periodically if he there is need to go washroom .

7. Change position of client every 2 hourly to avoid efforts make by client in moving his body by himself.

5.8 pressure injury prevention.

Pressure injury is also called bedsores and decubitus ulcers, that is developed when patient lie continuously on bed for several days with improper care, red blisters appear on the bony prominent site due to pressure against bed.

Nurses role.

1. Move patient every 2 hourly.

2. Keep patient away from moisture.

3. Elevate patients patient's body by applying bed rest.

4 massage client every morning with lotion and talcum powder.

5. Report physician at the beginning of pressure sore.

6. Change linen every day or when it is soiled as moisture enhances bacterial growth.

5.9 prevention of deconditioning.

Deconditioning is the condition which appears due to inactive body movements or bed rest ,which reduced functioning of body .

Elder client are the higher risk of developing deconditioning as their muscular and skeleton body alters due to bed confinement.

Nurses role

1.Assist client in walking , turning position, provide nutrition, maintaining hygiene.

2. Provide psychological support, social support and emotional support to the client

3. Planning to prevent from deconditioning should be done on the basis of client's need ,and need of every individual can be unique.

4. By providing care in all aspects can prevent patient from deconditioning.

Overall planning of health by providing sufficient medical care, nursing care, psychological care, emotional care can prevent client from deconditioning.