Nursing Interventions Essay Discussion Paper
Braden Scale Case Scenario Marion MacArthur is an 87 yr. old female pt. who has just been admitted to the long-term care / Family Practice floor where you are working. Marion normally resides alone in her own home in the local community. She had a fall 1.5 weeks ago & fractured her Rt. hip. She had a Rt. total hip replacement (THR) on her 2nd day of admission to the acute care hospital. She had some postoperative (after surgery) complications following the surgery. It was identified on day 4 of her stay that she had an adverse reaction to the analgesic – Morphine (morphine sulfate) that was being administered. She was excessively drowsy & could not be aroused. She ended up having the medication Narcan (naloxone) administered to reverse the narcotic analgesic effects Nursing Interventions Essay Discussion Paper.
She was then prescribed Toradol (ketorolac), a non-narcotic analgesic, which successfully managed her pain & caused no adverse effects. Now, she only takes extra-strength Tylenol (acetaminophen) for pain control & is well managed. She also had a deep vein thrombosis (DVT) in her Rt. lower leg/calf on day 3 following surgery & was required to keep her leg elevated on a pillow x 1 & use a compression stocking to that leg when ambulating. The DVT is considered to be almost a resolved issue at this point, but, because she presented with a DVT, she is considered to be at risk for future DVT & must be closely monitored. She is also now taking Coumadin (warfarin), an anti-coagulant blood-thinner to assist with the resolving of the DVT. Marion is now here, on your nursing unit, on day 7 postoperative. She is awaiting a geriatric assessment to see if she will be eligible to return to her own home. Occupational Therapy (OT) will also be assessing her activities of daily living (ADL) to determine her independence &/or need for assistance. The social worker will need to perform a consult with the pt. to see which services Marion will be eligible for on discharge. The geriatric assessment nurse & physician will also be assessing if she requires placement in a long-term care facility (LTC). Today is Monday & you will need to perform the Braden Scale assessment for Marion in addition to your shift assessment, including vital signs. For the purposes of this assessment, you will only complete the Braden Scale right now & identify if she is @ risk, moderate risk, high risk or very high risk for pressure injury (based on the score you assign to her) & which (if any) nursing actions will be required based upon your findings. Marion ambulates to the bathroom & up to the chair with the assistance of 1 staff member. She does not like to sit in the chair very long as she finds it uncomfortable. When she lays in bed, she can elevate her legs. She requires a lot of prompting to ambulate. OT has been working with her to find ambulating devices which she may be able to use @ home, such as a 4-point cane & a long grasping tool to reach items higher on shelves. Physiotherapy (PT) has been coming to get her up for a walk in the hallway once a day as well. One member walks behind her with a wheelchair in case she needs to sit down & take a break. Another member of PT holds the strap on the ambulation transfer belt as she walks & assesses her feet movements & general balance Nursing Interventions Essay Discussion Paper.
PT has requested that nursing staff take her for walks during the evening when possible using the same safety considerations. They are trying to help increase her mobility level. Marion also has 8 steps going into the entrance of her home. There are 6 steps downward to go to the laundry room & bathroom in her home. She would need to be prepared to walk up & down stairs at home so needs stability & balance for these actions. Marion’s dietary intake is fair at breakfast. She eats half of the toast x 2 with butter & marmalade, all of her tea with milk & sugar, one-third of the apple juice & a few bites of the oatmeal porridge but she does not eat the hard-boiled egg. She needs her meal tray to be set up, but she is able to feed herself. Today, she is scheduled for a shower using the shower chair. You learned in morning report that staff has been changing her bedsheets once daily for wetness (typically on the soaker pad & bottom bed sheet). When you greet Marion this morning & tell her that today is shower day, she immediately refuses, stating that she does not want to miss her visitors coming in today. She gets so few visitors that she needs this visit to help lift her spirits. If she is in the shower, they may leave. You notice that she has body odor & has been sweating. She really needs the shower. You tell her that you can get her up on the chair now & have another staff member assist you to get her washed up & her hair shampooed. It should take about 15 minutes & she can he all ready when visiting hours begin. She reluctantly agrees to this proposal. When you assist her to get undressed, you notice the smell of urine on her pants & underwear. You will use your observation skills to check for any signs if IAD (incontinence-associated dermatitis) when she is in the shower. You cover her up with blankets after assisting her to sit on the shower chair & go to the shower room. Your co-worker is already in there getting the proper temperature for the water. Mild hospital soap is in the room as well as baby shampoo. When you are washing her, you notice that she has some excoriated areas under both breasts, most probably from sweating in this area. Toward the end of the shower, when you are providing her peri care (perineum & surrounding area), you notice that she does indeed have some maceration in the folds of her groins & the creases are reddened & shiny. She tells that you are hurting her when you try to clean these areas. Marion’s labia (majora & minor) are both quite reddened. There is a whitish-colored, cottage cheese consistency discharge present on the perineum which you suspect to be candidiasis. You will note this in your shift assessment & mention it to the charge nurse for further investigation & report to the physician. You return Marion to her room & assist her to get dressed. She doesn’t want you to dry her off too well & she refuses to let you dry her pelvic region. You ensure that she has moisturizer applied to her skin , which is dry overall. She puts on her top clothing but requires assistance with her bottoms. She wears Tena ™ underwear. These are expensive & she only has a limited supply, so she wears the same pad all day when possible. This absorbent pad could possibly be holding some moisture next to her perineum all day long. She is supposed to wear the compression stocking to her Rt. leg when she ambulates, but she refuses it. She says it is “too tight” & she would rather stay in bed anyway. You do some pt. teaching about the reason for the compression stocking use & the benefits. She still refuses to put it on. You acknowledge her right to refuse but you will also mention this non-compliance with compression stocking wearing to the charge nurse. Just as you finish getting her dressed, PT comes in to take her for a walk in the hall. She is fine with doing this today because she may catch a glimpse of her visitors & wants them to see that she is doing well Nursing Interventions Essay Discussion Paper
- Pressure injury prevention: Based on the Braden Scale assessment, Marion may be at risk for developing pressure injuries. Therefore, nursing interventions should be implemented to prevent pressure injuries. These interventions include turning and repositioning her frequently, using appropriate pressure-relieving devices such as cushions and mattresses, and ensuring that her skin is kept clean and dry.
- Incontinence management: Marion has a history of urinary incontinence, which can lead to skin breakdown and other complications. To prevent this, nursing interventions should be implemented, such as providing incontinence care, ensuring that she is kept clean and dry, and using appropriate skin protectants to prevent skin breakdown.