Question

The nurse reinforces teaching for the caregiver on a immobile patient who will be discharged home soon. Which caregiver action when supervising care indicates the need for the nurse to intervene?

Answer 1

The various care giving action that indicate the need for the nurse to intervene when supervising care on an immobile patient are as follows:

• Identify complications of immobility (e.g., skin breakdown, contractures)
• Assess the client for mobility, gait, strength and motor skills
• Perform skin assessment and implement measures to maintain skin integrity and prevent skin breakdown (e.g., turning, repositioning, pressure-relieving support surfaces)
• Apply knowledge of nursing procedures and psychomotor skills when providing care to clients with immobility
• Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts)
• Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings, sequential compression devices)
• Educate the client regarding proper methods used when repositioning an immobilized client
• Maintain the client's correct body alignment
• Maintain/correct the adjustment of client's traction device (e.g., external fixation device, halo traction, skeletal traction)
• Implement measures to promote circulation (e.g., active or passive range of motion, positioning and mobilization)
• Evaluate the client's response to interventions to prevent complications from immobility