In: Nursing
CASE
Mrs. Smith, 73 years old, was brought to the emergency room due to
the in-car traffic accident. As a result of physical examination
and diagnostic tests, permanent paralysis (hemiplegia) was
determined on the left side and she was admitted to the neurology
clinic. Mrs. Smith, who has been inactive for a long time,
complains of constipation, urinary incontinence, insufficient sleep
and is fed with a nasogastric tube due to difficulty
swallowing.
QESTIONS
1. What are the risk factors for the bedsores? Which of these risk
factors are available to Mrs. Smith? Please write nursing
interventions to prevent bed sores in Mrs. Smith. (20
points).
2. What are the factors that cause constipation in Mrs. Smith?
Please write nursing interventions for constipation? (20
points).
3. Please write the interventions for Mrs. Smith to have adequate
and balanced sleep? (10 points).
4. Write down the mechanisms / physiopathology of respiratory
system problems (atelectasis, infection) that may develop in Mrs.
Smith, who is lying for a long time. And write down the preventive
interventions of respiratory system problems (atelectasis,
infection) that may develop in Mrs. Smith. (20 points).
5. Write the interventions to prevent the patient from falling
down? (20 points).
6. What do you do as a nurse to prevent the nasogastric tube from
clogging? (10 points).
Question 1
Answer: The risk is immobility or lack of change in position or lying down is the same position for a long period of time.
The patient has the risk for the development of bedsore as he is inactive for a long period of time.
The nursing interventions to prevent bedsore are
- Assess the skin condition properly especially the pressure point of the body.
- Check for any shin color changes in pressure point of the body
- Change the position of the patient every second hourly to increase blood circulation properly.
- Massage of the back or back massage should be done to increase blood circulation
- Use appropriate PH skin cleanser to prevent excessive dryness and excessive moisture.
- The nurse can use an air mattress for the patient. An Air mattress is a special mattress for the patient who is not able to move to prevent bedsore.
- Keep the skin clean and dry
- Provide a high protein diet to the patient to promote muscle strength.
Question 2
Answer: he patient is having constipation because of muscle weakness and nerve damage.
The factors that cause
-Nerve damage leads to a lack of impulse for the passing stool leads to constipation.
- immobility leads to constipation.
- an unusual position for a bowel movement that is used of bad pan
- lack of fluid intake
Nursing intervention for constipation
- Assess the condition of the patient
- Provide for fluid to the patient
- provide passive exercise
- provide a fiber-rich diet
- administered laxative if prescribed by the doctor
- change the position of the patient 2nd hourly
- Make a routine habit of passing the stool by using a bedpan.
Question 3
Answer: Intervention to have adequate and balance sleep
- Provide a comfortable position to the patient, this will helps to maintain proper sleep
- Provide one glass of warm milk to induce sleep
- provide warm sponge bath will help to improve sleep.
- Prevent caffeine at night, because it makes the person aroused
- Body massage can be provided
- Provide dim light for the room
- Avoid heavy meals and exercise at least 30 minutes before sleep. It should be taken early before bed.
- Prevent stressful environment like noise. Create a cooled and quiet environment to make proper sleep
Question 4
Answer: The patient is having muscle weakness leads to difficulty on removing the secretion produce in the respiratory system. The secretion block the airway leads to decrease oxygen supply to the alveoli leads to the collapse of lungs that is atelectasis and infection of respiration to the patient.
Preventive measure for the prevention of respiratory problems are
- the suction of the secretion if the patient is not able to remove by self. This will prevent the blockage of the airway.
- provide a fowler position to the patient.
- maintain proper personal hygiene, especially the mouth should clean every day
- Assess for vital signs, for fever, and increase respiratory rate.
- Administer prophylaxis antibiotics to prevent infection after prescribed by the doctor.
- Advice to performed breathing exercises if the patient is able to do it.
Question 5
Answer: The interventions to prevent fall form the bad are
- Restraint or side rail: Side rails should be provided for people who are bedridden. This will helps in preventing falls from the bed.
- the assistance should be provided while doing any activities to prevent form fall.
- the compulsory attendants should be present near the patient. The family member is advised to present near the patient all the time.
- Make the bed lower position, this will help to reduce the severity of injury level if fall also
- place bell ring near to the patient, so that he can call the nurse whenever he needed.
- Check the safeness of the environment every day to prevent falls.
- While shifting the patient, the patient should shift properly form one bed to another bed with the help of others nurses to prevent falls.
-Explained preventive measure for fall to the family members.
Question 6
Answer: Nasogastric tube is the tube use to feed the patient by inserting through the nose and enter the stomach.
Prevention of a Nasogastric tube is that
-The nurse should flush the tube before and after feeding with clean water. This will helps to remain any feed inside the tube after feeding
- Do not feed solid food through it. The feeding diet should be a full liquid diet
- Before feeding any tablets, crush it properly mix with juice or water or milk and feed it.
- Administered all medications separately.