Question

Communicating and reporting a client's response to Nursing interventions The Nursing Care Plan states that a particular client may mobilise with a four wheel frame and transfer with supervision by one Nurse. However, you observe that they have difficulty getting out of bed and are unsteady on their feet. What are your actions? [Consider immediate action and further recording and reporting requirements]

Answer 1

A patient who has to be mobilized should have a physician order and a nurse is chiefly involved in the mobilisation

The immediate actions to be considered are

• Assess for any complaints of pain to rule out the reason for instability
• Monitor vital signs ,to collect the baseline data(for instance if patient has postural hypertension, the patient will have dizziness on standing)
• Ensure whether patient is in need of a physiotherapist help for mobilisation
• If patient has the strength to stand with help,an additional support of manpower from the healthcare professionals can be provided for patient to gain hope and confidence to step out and walk
• Assess the post operative recovery period of this patient

The reporting has yo be done in the following way

• Record the reason for inability of the patient to walk
• Ensure the treating provider is updated for further action
• Report to the treating doctor
• Check for surgeons order