Exam (elaborations) NURS 3330 TIM JONES ROOM 308 MED SURG (ALL EVALUAT

Exam (elaborations) NURS 3330 TIM JONES ROOM 308 MED SURG (ALL EVALUAT Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing were noted to his shoulders, lower back, ribs, and thighs. Admitted to Med-Surg for new onset confusion. Mr. Jones is guarded and has facial grimacing anytime someone reaches toward him or touches him. He does moan when rolled. You responded correctly to 6 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Mr. Jones needs reassurance that he is in a safe place and that the staff want to help him. He also needs education on pain medication. Fall Risk Increased acuity Mr. Jones is 82 years old and confused. Health change Increased acuity New onset bruising as well as various stages of bruise healing noted. Neurological Increased acuity Patient is experiencing new onset of confusion. This study source was downloaded by from CourseH on :47:36 GMT -05:00 This study resource was shared via CourseH NURS 3330 TIM JONES ROOM 308 MED SURG (ALL EVALUATIONS) Category Your response Explanation Pain level Increased acuity Mr. Jones moans when rolled and has several wounds. Psychological Needs Increased acuity Mr. Jones is guarded and grimaces anytime someone reaches toward him. You correctly diagnosed 7 out of 7 options: Physiological Description Your Response Explanation Decisional conflict False Scenario does not support this diagnosis. Defensive coping True Related to fear of abuse as a result of onset bruising and facial grimacing. Disturbed sleep pattern False Scenario does not support this diagnosis. Ineffective health maintenance True Patient is unable to protect himself from harm. Risk for spiritual distress False Scenario does not support this diagnosis. Safety Description Your Response Explanation Isolation precautions False Scenario does not support this diagnosis. Risk for injury at home True Related to presenting with different stages of bruising while in nursing home. Scenario 1 You correctly ordered 5 out of 5 actions: This study source was downloaded by from CourseH on :47:36 GMT -05:00 This study resource was shared via CourseH Your order Correct order Step Explanation 1 1 Wash hands. Hand washing is the best prevention to spreading disease. 2 2 Reassure patient that he is in a safe environment. Due to patient guarded behavior, the nurse seeks to reassure the patient to provide comfort. 3 3 interviewing patient regarding need for hospitalization Interviewing is part of the assessment process and allows the nurse to establish rapport with the patient and gives the patient the opportunity to explain the presence of injuries. 4 4 Complete physical assessment. Physical assessment provides the nurse with objective data. 5 5 Notify Charge Nurse and Social Services. If physical abuse or neglect is suspected, health care professionals are required to file a report with adult protective services. Scenario 2 You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Use therapeutic communication. Mr. Jones is guarded and this provides an opportunity for him to discuss what has caused his bruising. 2 2 Seek clarification from Mr. Jones on why he does not want to leave the room. Clarification is part of the therapeutic communication milieu. 3 3 Reassure Mr. Jones that he will be safe during his hospital stay. Reassurance offers needed Therapeutic communication for the patient 4 4 Administer prescribed anxiolytic medication prior to transfer to CT area. Anxiolytic therapy may assist with comfort and relief from anxiety. 5 5 Offer UAP to accompany Mr. Jones during the CT process. Having someone present with Mr. Jones reinforces the safe care environment. Scenario 3 This study source was downloaded by from CourseH on :47:36 GMT -05:00 This study resource was shared via CourseH You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Assess Mr. Jones for injuries. Assessment is always the first step of the nursing process. 2 2 Assist Mr. Jones back to bed. After assessment and determining there are no reasons not to move Mr. Jones, assist him back to bed. 3 3 Provide personal hygiene. Urine or feces left on skin can lead to skin breakdown. 4 4 Remind Mr. Jones to seek assistance before getting out of bed. Reorientation to call light and fall precautions reduces risk for injury. Ensure call light is within reach before leaving the room – provides Mr. Jones with a means to communicate the next time he needs assistance. 5 5 Obtain a sitter to stay with patient. Patients who are confused may require one-on-one care to increase patient safety. Scenario 4 You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Notify healthcare provider for change in respiratory assessment. There is a significant change in respiratory status that needs to be addressed. 2 2 Administer nebulizer treatment per HCP order. Provide nebulizer treatment to assist opening up airways to ease breathing. 3 3 Reassess respiratory status. After treatment with nebulizer, reassessment of the lungs is needed to evaluate the effectiveness of the treatment. 4 4 Encourage Mr. Jones to cough and take