Instructions
Mr. Joe Smith, 75-year old man, recently suffered a left cerebrovascular accident. He has right visual
field deficits and residual weakness in this right arm and leg. He uses a walker for mobility. He takes
Metoprolol for his blood pressure and the physician started him on Coumadin because he has recently
been diagnosed with atrial fibrillation.
Select appropriate nursing interventions when providing multidimensional care to clients
experiencing alterations in mobility.
Strategies for safe effective multidimensional nursing practice when providing care for clients
experiencing sensory and perception disorders.
Regularly check and maintain his blood pressure.
Slight increase or decrease in the blood pressure can cause blood flow problem and ultimately can lead
to cerebral ischemia.
Give him ROM on his left side.
Range of motion will increase blood flow to muscles and will regain its strength.
Show him how to properly use walker.
The proper use of walker will reduce his fall risk.
Prevent him from any kind of injury i.e., trim his nails, fall injury.
Because he is on anticoagulant and carry more chances of bleeding and blood loss.
Home modifications to reduce falls in the elderly-
Falls are a significant health concern for the elderly because of their frequency and the potential for
serious consequences.
• Overall decrease in fall risk, especially among those with a history of falling, when modifications such
as nonslip bath mats, lighting at night, and stair rails were recommended.
• Home modification in the absence of other intervention approaches may be effective for persons with
a history of falling but is likely to be most effective when integrated into a multifaceted intervention
program that also focuses on medications, exercise, and nutritional status.
4. Modifications to protect the child pedestrian-
The main reason of accident is that children, especially young children, are not cognitively ready to
handle the complex traffic environment. Challenges for children include difficulty seeing and processing
traffic patterns, judging speed of vehicles, prioritizing street-crossing activities, and choosing an
adequate gap in traffic to cross the road.
Environmental approaches that separate children from the traffic environment and slow traffic in places
where children might be in the street would be effective.
For example, using fences to physically separate children from driveways was associated with a threefold
decrease in driveway-related child pedestrian injuries.
ANSWER 2.
Appropriate nursing interventions when providing care to the client experiencing mobility alterations-
1.Assist patient for muscle exercises as able or when allowed out of bed; execute abdominal-tightening
exercises and knee bends; hop on foot; stand on toes.
2. Present a safe environment: bed rails up, bed in down position, important items close by.
3. Establish measures to prevent skin breakdown and thrombophlebitis from prolonged immobility:
Clean, dry, and moisturize skin as necessary.
Use anti embolic stockings or sequential compression devices if appropriate.
Use pressure-relieving devices as indicated (gel mattress).
4. Execute passive or active assistive ROM exercises to all extremities.
5. Provide foam or flotation mattress, water or air mattress or kinetic therapy bed, as necessary.
6. Promote and facilitate early ambulation when possible. Aid with each initial change: dangling legs,
sitting in chair, ambulation.
7. Show the use of mobility devices, such as the following: trapeze, crutches, or walkers.
8. Help out with transfer methods by using a fitting assistance of persons or devices when transferring
patients to bed, chair, or stretcher.
9. Give positive reinforcement during activity. Patients may be unwilling to move or initiate new activity
because of fear of falling.
10. Encourage resistance-training exercises using light weights when suitable.
11. Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or
prefabricated splints.
12. Encourage coughing and deep-breathing exercises. use suction as necessary. Make use of incentive
spirometer.(Perry, A. G, 2019)
APPROPRIATE NURSING INTERVENTION FOR PATIENT WITH SRNSORY AND PERCEPTION DISORDER-
1.Provide a consistent physical environment and a daily routine.
2. Provide access to familiar objects, when possible.
3. Provide a low-stimulation environment for patient because
disorientation may be increased by overstimulation.
4. Provide for adequate rest, sleep, and daytime naps.
5. Use a calm and unhurried approach when interacting with patients.
6. Speak to the client in a slow, distinct manner with appropriate
volume.
Engage patient in concrete "here and now" activities (that
is, ADLs) that focus on something outside the self that is concrete
and reality oriented.
7. Facilitate use of hearing aids, as appropriate.
8. Listen attentively.
9. Use simple words and short sentences, as appropriate.
10. Obtain patient's attention through touch.
Answer 3.
Nursing Interventions for Joe Smith
Nursing care has a significant impact on the patient's recovery. In summary, here are some nursing
interventions for patients with stroke:
1. Positioning- Position to prevent contractures, relieve pressure, attain good body alignment, and
prevent compressive neuropathies.
2. Prevent flexion- Apply splint at night to prevent flexion of the affected extremity.
3. Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
4. Prevent edema. Elevate affected arm to prevent edema and fibrosis.
5. Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
6. Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the
patient to thrombosis and pulmonary embolus.
7. Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing
and begin walking as soon as standing balance is achieved.
8. Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.
9. Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual
perception is intact.
10. Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in
teaching alternate swallowing techniques.
11. Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patient's voiding schedule.
12. consistent in patient's activities. Be consistent in the schedule, routines, and repetitions; a written
schedule, checklists, and audiotapes may help with memory and concentration, and a communication
board may be used.
13. Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and
dependent body parts.
14. Monitor the level of PT/INR as patient on coumadin for risk of bleeding. (Verloo, H, et al 2019)
Step-by-step explanation
References
Perry, A. G., Potter, P. A., & Ostendorf, W. (2019). Nursing Interventions & Clinical Skills E-Book. Elsevier
Health Sciences
