Question

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place,and time and can follow directions. Identify 5 nursing interventions and the rationales for each intervention that the nurse should take to prevent falls. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Identify 5 nursing interventions and the rationales for each intervention that the nurse should take as part of seizure precautions. A nurse observes smoke coming from under the door of the staff’s lounge. Identify and define the fire response sequence (acronym) along with how to use a fire extinguisher. A nurse is caring for a patient who has experienced an ischemic stroke. Identify 5 physical assessment findings associated with a left cerebral hemispheric stroke and 5 physical assessment findings associated with a right cerebral hemispheric stroke.

Answer 1

NURSING INTERVENTION AND RATIONALE FOR FALL PREVENTION

1 ASSESSMENT : EARLY IDENTIFICATION OF CATEOGRIES OF PATIENT WHO IS AT RISK OR HIGH RISK OF FALL .SUCH A PRECATUION WOULD HELPFUL FOR HEALTH CARE PROFESSIONALS TO ENSURE ADDITIONAL SAFETY MEASURES SUCH AS PROVIDING SIDE RAILS , RESTRAIN THE PATIENT ON ACCOUNT OF RESTRAIN POLICY ,PROVIDE FREQUENT MONITIORING AND ASSISTANCE.

2    CLIENT EDUCATION : ADEQUATE AWARENESS WOULD MAKE THE CLIENT I TSELF BE ALERT THE RISK OF FALLING .THIS MAKES THEM MORE ALERT AND SEEK AID IF THEY REQUIRE.

3 ADEQUATE ENVIORNMENT ; EXAMINE THE ENVIORNMENT OF PATIENT FOR WET ,POOR LIGHTINING ,CLUTTER AND THE PRESENCE OF HARMFUL AND SHARP OBJECTS .SUCH VIGILANCE REDUCE THE CHANCE OF FALLING AND RISK FACTORS

4 NUTRITIONAL SUPPLEMENTS ; THIS WOULD HELPS THE PATIENT ESPECIALLY THE AGED TO MAINTAINED BALANCED DIET .DIET SHOULD INCLUDE PROTEIN AND VITAMIN CONTENTS .HELPING IT FOR PATIENTS WITH BONE DISORDERS AND ABNORMALITIES AND WEAKNESS

5 FALL PREVENTION COMMITEE ; THIS GROUP INCLUDES THE SERVICES OF NURSES ,GENERAL PRACTIONERS ,AND PHYSITHERAPIST .THEY CAN COORDINATE DIFFERENT SERVICES AND ENSURE EARLY CARE IF ANY EMERGENCY HAPPENS

6 DOCUMENTS ; KEEP DOCUMENTS OF  INCIDENTS AND FOLLOW UP CARE FOR SAFETY AND LEGAL VALIDITY

NURSING INTERVENTION AND RATIONALE FOR SEIZURE PRECAUTION

1 SCENE SAFETY : CLEAR THE AREA TO AVOID INJURY AND REDUCE THE RISK OF FURTHER COMPLICATIONS SUCH AS HEADINJURY ,FRACTURES

2    POSITION ; RECOMMENDED POSITION IS KEEPING THE PATIENT IN SIDE LEFT LATERAL POSITION AND CLEAR AIRWAY AND DO SUCTIONING..INADDITION TO REMOVE ANY FOREIGN OBJECTS FROM MOUTH LIKE DENTURES .

3 ASSESSMENT ; TYPES AND DURATION OFSEIZURE FOLLOWED BY COLLECTING PREVIOUS HISTORY IF ANY .THIS WOULD IMPORTANT FOR FURTHER FOLLOW UP.

4 MEDICATION ; ADMINISTER ANTI EPILEPTIC AS PER THE INSTRUCTION AND SUPERVISION OF DOCTORS AND FOLLOW UP CARE

5 HEALTH EDUCATION AND DOCUMENTATION ; EDUCATION THE PATIENT ABOUT HIS /HER CONTION AND REASSURE THEM . DOCUMENTS ALL MODE OF TREATMENT CLEARLY .

FIRE RESPONSE SEQUENCE AND USE OF FIRE EXTINGUISHER

YOU MUST FOLLOW R .A. C.E BEFORE ATTEMPTING TO EXTINGUSH FIRE

R EMOVE / RESUCE ANY PERSON FROM SCENE

ALERT / ACTIVATE EMERGENCY NUMBER FOR HELP

CONFINE CLOSE ALL DOORS OF FIRE AREA

EXTINGUISG /EVACUATE  

FIRE EXTINGUISHER OPERATION

PULL ; PULL THE SAFETY PIN ON THE EXTINGUISHER

AIM ; AIM THE HOSE OF THE EXTINGUISHER AT THE BASE OF FIRE

SQUEEZE ; SQUEEZE THE HANDLE TO DISCHARGE THE MATERIAL

SWEEP; SWEEP THE HOSE ACROSS THE BASE OF THE FIRE FROM SIDE TO SIDE

PHYSICAL ASSESMENT FINDINGS OD RIGHT AND LEFT CEREBERAL HEMISPHERIC STROKE

FOR LEFT CEREBERAL HEMISPHERIC STROKE

1 RIGHT SIDE WEAKNESS , RIGHT SIDE PARALYSIS .NUMBNESS OF FACE ARM

2 RIGHT FACIAL DEVIATION

3 SLURRING OF SPEECH

4 VISION PROBLEMS IN RIGHT EYE

5 SLOW ,CAUTIOUS BEHAVIOURAL STYLE

RIGHT CEREBRAL HEMISPHERIC STROKE

1 LEFT SIDE PARALYSIS ,WEAKNESS ,NUMBNESS OF FACE ARM

2 LEFT SIDE FACIAL DEVIATION

3 SPEECH /LANGUAGE PROBLEM

4 VISION PROBLEMS

5 QUICK ,INQUISITIVE BEHAVIOURAL STYLE