Patient David Montanez Simulation Lab

Simulation Lab 1. The nurse is responsible to assess the patients pain level to ensure pain is being managed effectively. This is a priority assessment that allows the nurse to provide individualized interventions and to advocate for their patients when necessary. The nurse should reassess the patient’s pain level at least 30 minutes after administering pain medication for effectiveness. The nurse should implement ambulation and increase activity as soon as possible and as ordered by physician. Getting up and moving is so helpful for post-op patients to “wake everything up” after anesthesia. Assist the patient to dangle their legs off the side of the bed with their feet flat on the ground. Encourage the patient to sit up straight and take deep breaths. Assess for dizziness before advancing to a standing position. Create a realistic activity list that the patient can complete to keep them involved in their daily care. Implement deep breathing exercises for post-operative patients to achieve optimal lung expansion and gas exchange to prevent pneumonia. The nurse should encourage patients to use the Incentive spirometer at least ten times an hour. Educate the patient and the family on the importance and proper technique. The nurse may instruct the patient to turn, yawn, cough, and breathe deeply every 1-2 hours while they are awake as alternative deep breathing exercises. 2. A patient with immobility issues is at risk of developing complications depending on the length of time and degree of immobility. While auscultating the lungs and breath sounds, the nurse may hear crackles due to decreased respiratory movement. Encourage the patient to cough and if productive, note the color, amount, consistency, and odor of the secretions. Other assessment findings that can occur due to immobility include muscle atrophy, foot drop, and decreased peristalsis. 3 3. Complications for all body systems as a result of immobility are listed below:  Neurological: Immobile patients have decreased circulation due to inactivity which can cause changes in emotional status. Patients may experience anxiety, depression, hostility, and altered wake/sleep patterns. Mental status (A&O) is a priority assessment performed at beginning of patient/nurse interaction. This provides the nurse with a baseline to refer back to if necessary (ex: sudden change in pt. status or disorientation). Decreased circulation can also cause numbness and tingling, especially in patients’ feet and hands.  Respiratory: immobility puts patients at a high risk for developing pneumonia due to decreased lung expansion and secretion movement. The nurse may hear crackles or wheezing when auscultating the lungs and breath sounds. The client should be turned at least every 2 hours and raise head of the bed elevated at least 30 degrees to allow the chest wall to expand more fully. Encourage the patient to cough/yawn and to use their incentive spirometer at least 10 times an hour while awake.  Cardiovascular: edema and swelling in the lower extremities may occur when a patient is immobile over time which puts them at a higher risk for developing deep vein thrombosis. Educating the patient on the importance of SCD use is important for prevention. Elevating their legs on pillows is an alternative if they do not like the scd machine.  Integumentary: immobile patients are at a high risk for skin break down. An immobile patient must be repositioned at least every two hours. The patient is positioned on their left and/or right side and supported by pillows or wedges to 4 help relieve pressure off their sacrum which helps to prevent pressure ulcers from occurring. Other causes of pressure ulcers are equipment such as nasal cannula pressure on the patients face and behind their ears. Applying a foam over the tubing helps prevent skin breakdown from occurring. It is important to ensure that the patient is clean and dry and to check their skin for redness and signs of breakdown. A good time to check is during Q2 repositioning.  Gastrointestinal: Constipation is very common for immobile patients. It is important to encourage the patient to drink fluids and stay hydrated to increase peristalsis. The patient should also be educated on the importance of consuming foods high in fiber and fruits and vegetables. Constipation can be very uncomfortable and frustrating for the patient. If the patient is unable to get out of bed to use the bathroom, position the head of the bed into high fowlers when they are on the bed pan. This helps to simulate sitting on a toilet, making it easier to go. Elderly patients should be offered toileting more frequently, especially after meals. Stool softener may be given to assist with bowel elimination, laxatives should be a last resort.  Musculoskeletal: Immobility can be very damaging to the MS system. Range of motion exercises are a priority to prevent muscle atrophy, contractures, and foot drop from occurring. Encourage patients to perform ROM exercises two to three times per day while in bed or in the chair. Encourage and monitor calcium intake.  Genitourinary: Immobile patients are at a higher risk for bladder retention. Gravity plays a big role in urination and when patients are unable to move around this may be compromised. It is important to offer frequent toileting, especially for 5 incontinent patients. Immobile patients are at a higher risk for developing UTIs. It is important to give patients daily baths, as well as perform perineal care after they void/ have a bowel movement to reduce their risk for infections. Ensuring adequate oral fluid intake is being received is a key part as well.  Metabolic: weight loss, decrease in appetite, decrease in protein causing muscle loss, resorption of calcium from bones, hypercalcemia due to decreased urinary elimination of calcium. Assess height, weight, skin turgor, wound healing, I&O’s, and lab values. Provide appropriate nutritional therapy. For patients who can eat, encourage high-calorie/protein diet with vitamin B and C supplements.