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96/Male/DNR/NKA (BPH (Urinary retention, Risk for acute pain, Risk for…

- - - - Teach client how to safely ambulate at home, including using safety measures such as handrails in bathroom. This will help relieve anxiety at home and eventually decreases the risk of falls during ambulation.
      - Improve home supports. Many community service organizations provide financial assistance to make older adults make safety environments in their homes.
      - Wheelchairs, unfortunately, serve as a restraint device.
      - Avoid use of wheelchairs as much as possible because they can serve as a restraint device. Most people in wheelchairs do not move.
      - Ask family to stay with the patient. This is to prevent the patient from accidentally falling or pulling out tubes.
      - If patient has a new onset of confusion (delirium), provide reality orientation when interacting. Have family bring in familiar items, clocks, and watches from home to maintain orientation. Reality orientation can help prevent or decrease the confusion that increases risk of falling for clients with delirium.
      - Provide high-risk patients with a hip pad. These pads when properly worn may reduce a hip fracture when fall happens.
      - Consider physical and occupational therapy sessions to assist with gait techniques and provide the patient with assistive devices for transfer and ambulation. Initiate home safety evaluation as needed. The use of gait belts by all health care providers can promote safety when assisting patients with transfers from bed to chair. Assistive aids such as canes, walkers, and wheelchairs can provide the patient with improves stability and balance when ambulating. Raised toilet seats can facilitate safe transfer on and off the toilet.
      - Inform patient the advantage of wearing eyeglasses and hearing aids and to have these checked regularly. Hazard can be reduced if the patient uses appropriate aids to promote visual and auditory orientation to the environment. Visual impairment can greatly cause falls.
      - Allow the patient to participate in a program of regular exercise and gait training. Studies recommend exercises to strengthen the muscles, improve balance, and increase bone density. Increased physical conditioning reduces the risk for falls and limits injury that is sustained when fall transpires.
      - Consider using sitters for patients with impaired ability to follow direction who are at risk for falls. Sitters are effective for guaranteeing a secure, protected, and safe environment.
      - Collude with other health care team members to assess and evaluate patient’s medications that contribute to falling. Examine peak effects for prescribed medications that affect level of consciousness. A review of the patient’s medications by the prescribing health care provider and the pharmacist can identify side effects and drug interactions that increase the patient’s fall risk. The more medications a patient takes, the greater the risk for side effects and interactions such as dizziness, orthostatic hypotension, drowsiness, and incontinence. Polypharmacy in older adults is a significant risk factor for falls.
      - When patient experiences weakness and impaired balance, this chair style will be useful and easier to get out of.
      - Provide the patient with chair that has firm seat and arms on both sides. Consider locked wheels as appropriate.
      - Audible alarms can remind the patient not to get up alone. The use of alarms can be a substitute for physical restraints.
      - Bed and chair alarms must be secured when patient gets up without support or assistance.
      - Patients having difficulty in balancing are not skilled at walking around certain objects that obstruct a straight path.
      - Provide heavy furniture that will not tip over when used as support when patient is ambulating. Make the primary path clear and as straight as possible. Avoid clutter on the floor surface.
      - The patient must get used to the layout of the room to avoid tripping over furniture.
      - Familiarize the patient to the layout of the room. Limit rearranging the furniture in the room.
      - Nonskid footwear provides sure footing for the patient with diminished foot and toe lift when walking.
      - Encourage the patient to don shoes or slippers with nonskid soles when walking.
      - Patients, especially older adults, has reduced visual capacity. Lighting an unfamiliar environment helps increase visibility if the patient must get up at night.
      - Guarantee appropriate room lighting, especially during the night.
      - Studies demonstrate that regular use of restraints does not reduce the incidence of falls.
      - Avoid the use of restraints to reduce falls.
      - According to research, a disoriented or confused patient is less likely to fall when one of the four rails is left down.
      - Use side rails on beds, as needed. For beds with split side rails, leave at least one of the rails at the foot of the bed down.
      - Keeping the beds closer to the floor reduces the risk of falls and serious injury. In some healthcare settings, placing the mattress on the floor significantly reduces fall risk.
      - See to it that the beds are at the lowest possible position. If needed, set the patient’s sleeping surface as adjacent to the floor as possible.
      - This is to prevent the patient from going out of bed without any assistance.
      - Respond to call light as soon as possible.
      - Items that are too far from the patient may cause hazard and can contribute to falls.
      - Move items used by the patient within easy reach, such as call light, urinal, water, and telephone.
      - Nearby location provides more constant observation and quick response to call needs.
      - Transfer the patient to a room near the nurses’ station.
      - Signs are vital for patients at risk for falls. Healthcare providers need to acknowledge who has the condition for they are responsible for implementing actions to promote patient safety and prevent falls.
      - For patients at risk for falls, provide signs or secure a wristband identification to remind healthcare providers to implement fall precaution behaviors.
      - For the patient in the hospital or long-term care setting:
- - - - Risk for Injury
      - Wandering
      - Compromised Family Coping
      - Social Isolation
      - Disturbed Sensory Perception
      - Disturbed Sleep Pattern
      - Impaired Physical Mobility
      - Self-Care Deficit: Toileting
      - Self-Care Deficit: Dressing and Grooming
      - Self-Care Deficit: Bathing/Hygiene
      - Impaired Verbal Communication
      - Chronic Confusion
      - Disturbed Thought Process
- - - - Cluster care; maximize rest
        
        Prevents joint stiffness and immobility
        
        Assist with AROM or PROM
        
        Prevents dehydration and aides in the excretion of uric acid
        
        Promote fluids
        
        Enables you to know if symptoms are worsening or resolving (therefore telling you if interventions are working)
        
        Closely monitor amount of inflammation at joint
        
        Patients may have an impaired ability to mobilize due to inflammation and pain; assist for safe ambulation and transfer
        
        Assist with mobility
        
        Patients in an acute attack will experience pain and require appropriate pain control and interventions
        
        Treat pain: administer meds, apply warm or cool compresses, positioning
        
        Joint pain, particularly in the foot, will put them at higher risks for fall and injury due to their impaired mobility.
        
        Initiate fall precautions/prevent injury
        
        Doing so decreases the likelihood of future flare ups and/or attacks
        
        Educate about dietary and lifestyle changes (decreasing alcohol intake, foods high in purines, foods/drinks sweetened with fructose, weight reduction, adequate hydration)
- - - - Wear gloves during any contact with mucus, blood, and other body fluids. Use goggles when appropriate.
        
        Strictly observe sterile technique when inserting urinary catheter. Ensure that catheters are cared for every shift. The Genito-Urinary tract is one of the most common site for nosocomial infections.
        
        Help patient change positions frequently. It prevents stasis of secretions and pathogens in the lungs and bronchial tree.
        
        Encourage patient to eat a balanced diet. A balanced intake of omega 3 and omega 6 fatty acids, protein, vitamins A, C and E, zinc and iron is essential in reducing risk of infection.
        
        Encourage adequate rest. It can reduce stress and boost the immune system.
        
        Encourage patient to increase fluid intake if not contraindicated. It helps thin out secretions and replace fluid loss during fever. It also prevents stasis of urine by promoting diluted urine and frequent emptying of bladder.
        
        Wash hands and encourage the patient to do the same. Dry hands with a paper towel after washing. Handwashing is an effective technique to prevent the spread of infection. Dry surfaces are better in preventing transfer of microorganisms.
        
        Monitor the patient for any signs of swelling, purulent discharge or presence of pain from wounds, injuries, catheters or drains. These are the classic signs of infection.
        
        Assess temperature of neutropenic clients every 4 hours. Neutropenic patients may not have adequate inflammatory response. In most cases, fever is the only symptom they’ll show.
        
        Check the patient’s immunization history. People with insufficient immunization may not have adequate acquired immunity.
        
        Take note of the patient’s current medications, like corticosteroids and antineoplastic agents. Some medications and treatment modalities causes immunosuppression.
        
        Routinely monitor the patient’s white blood cell count, serum protein, and serum albumin. These laboratory values are closely linked to the patient’s nutritional status and immune function.
        
        Assess the skin for color, texture, elasticity, and moisture. Proper skin assessment and documentation facilitates prevention of the breakdown of skin breakdown which is the body’s first line of defense againts pathogens.
- - - - Digitally eliminate the fecal impaction. Stool that remains in the rectum for long periods becomes dry and hard; debilitated patients, especially older patients, may not be able to pass these stools without manual assistance.
        
        Encourage a regular period for elimination. Most people defecate following the first daily meal or coffee, as a result of the gastrocolic reflex.
        
        Urge patient for some physical activity and exercise. Consider isometric abdominal and gluteal exercises. Movement promotes peristalsis. Abdominal exercises strengthen abdominal muscles that facilitate defecation.
        
        Assist patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetable, whole grains) per day. Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged.
        
        Encourage the patient to take in fluid 2000 to 3000 mL/day, if not contraindicated medically. Sufficient fluid is needed to keep the fecal mass soft. But take note of some patients or older patients having cardiovascular limitations requiring less fluid intake.