NSB131 : Integrated Nursing Practice

Problem

Nursing interventions

Rationale

High risk for falls

1. A secure wristband identification can be implemented for risk for fall behaviour  

2. The move items that patient use should be kept within his reach like urinal, telephone and water.

3. Nurse should respond to the call light immediately when called by the patient.

4. Side rails should be used when required and in case of split side rails, one of the rails should be kept down at the foot of the bed.

5. There should be proper light in the room.

6. There should be no cluttering of the patient’s primary path with any sort of furniture. Chairs, beds and bathroom fittings should be supported or assisted with alarms

1. By using wristbands, healthcare professionals would be able to acknowledge the condition and the patient whereabouts promoting patient safety and prevention of falls (Urquhart Wilbert, 2013).

2. Items kept far away from the patient can contribute to risk of falls and may be hazardous.

3. This would prevent the patient from getting up from the bed without any assistance.

4. If one of the rails is kept down, it reduces the chances of falls for a confused or disoriented person (Ganz et al., 2013).

5. This would help in increased visibility and reduced chances of falling if the patient gets up at night.

6. The patient may find it difficult to walk around objects obstructing their primary path.

Skin integrity impairment

1. Monitoring of the site of impaired skin integrity once daily for any changes like redness, colour changes, warmth, swelling, pain or any chances of infection on the scalp due to psoriasis

2.   Monitoring of skin care practices by noting down cleaning schedule, type of soap used, water temperature and cleansing frequency.

3. Monitoring of vital signs at regular intervals

4. Antibiotic administration and tell the patient not to scratch or rub the scalp and use gloves, of necessary

5. A diet plan is necessary for nutritional needs

6. Bath oil can be used

1. Systematic inspection of the scalp can help in the identification of impending problems (Talan et al., 2015).

2. Individualized plan of care is important for psoriasis depending upon skin needs, condition and preferences.  

3. This can be helpful in examining skin under general circumstances and occurrence of no new injuries.

4. Topical agents can be helpful in fighting infection. Rubbing or scratching can delay healing and cause further injury.

5. High-calorie and protein diet can  be helpful in promoting healing (Barrea et al., 2016)

6. This helps in the reduction of scales formation and keep the skin moist to avoid itching or rubbing

cardiac insufficiencies in renal failure

1. Auscultation of lung and heart sounds. Evaluation of peripheral oedema presence, dyspnea and vascular congestion

2. Hypertension assessment with monitoring of BP and noting of postural changes like lying, sitting and standing

3. Evaluation of heart sounds, capillary refill, temperature or sensation

4. Assessment of activity level

5. Monitoring of urine input and output along with vital signs of heart

6. Patient education on diet and nutrition

1. Tachycardia, tachypnea, irregular heart rate, wheezes and muffles tones in S3 and S4 indicate heart failure due to renal failure

2. Hypertension is caused due to RAA system because of fluid deficit and response to side effects of anti hypertension medicines (Te Riet et al., 2015)

3. Narrow pulse pressure, pallor, sudden hypotension with mental deterioration can cause tamponade

4. Weakness can contribute to anaemia and heart failure

5. Urine retention and continence can be evaluated through urine input and output as the patient is suffering from renal failure. Foley catheter can be used in case of incontinence.

6. Limiting of salt intake and daily weights is important in case of renal failure (Ha, 2014)

behavior issue- agitation, aggression and confusion

1. Assessment of frequency of agitating and aggressive behaviour, stressors that precede such behaviour

2. Identification of feelings experienced by the patient preceding aggression

3. In every shift, the nurse should assess the thought ability of the person by observing memory changes, cognitive functioning, and changes in thinking and difficulty in communication.

4. Assessment of level of disorientation or confusion

5. Utilization of cognitive function testing

6. Provide the patient with positive reinforcement strategies and feedback for positive behaviours

1. Identification of circumstances and patterns surrounding this type of injury can help in designing nursing interventions and teaching activities according to patient preferences (Maki, Yamaguchi & Yamaguchi, 2013)

2. Feelings serves as guidelines for interventions planning

3. Any type of change in these statuses may indicate deterioration or improvement in mental health status (Freitas ett al., 2013).

4. This would be helpful in assessing the effectiveness of treatment or deterioration in condition.

5. The current level of Alzheimer can be determined

6. This greatly reinforces progress and boost patient’s confidence