Nursing Interventions and Priorities: Case Studies

Exc. 2 1. A woman, 45 years old, diagnosed with stroke, was admitted to the hospital with complaints of pain and heat in the buttocks area since one week ago. Examination results: the patient cannot walk, activities are assisted, the patient's buttocks area is red due to sleeping in the same position for a long time.What is the appropriate nursing intervention for this patient? A. Help the patient with activities B. Attach the sole support C. Teach and facilitate walking aids D. Massage the area of the bony prominences E. Provide cushioning to the area of the bony prominence Answer Key: E. Provide cushioning to the area of the bony prominence. Discussion: a. In the question above, focus on the statement of sleeping in the same position for a long time. This condition will certainly result in decubitus (pressure sores) in the patient. So the appropriate nursing action for the above case condition is to provide padding at the point of the bony prominence which is an area that is very at risk of developing pressure sores. b. The options in points a, b and c are additional interventions that can be carried out in the cases above to help the patient with mobilizationbut it's notas the main intervention. c. Answer choice point d isinappropriate interventionbecause the area of the bony prominence should not be massaged. 2. A man, 48 years old, diagnosed with coronary artery disease, was hospitalized with complaints of left chest pain radiating to his back and left hand since 2 days ago. The patient said the pain was like being crushed by a heavy object on a scale of 7, weakness, unable to sleep, shortness of breath. Examination results: looked grimacing in pain, pale, BP 140/90 mmHg, pulse rate 110x/minute, respiratory rate 24x/minute, temperature 380 C. What is the main nursing problem in this case? A. Acute pain B. Hyperthermia C. Activity intolerance D. Sleep pattern disturbance E. Changes in breathing patterns Answer Key: A. Acute pain Discussion: In determining the main nursing problem, it must refer to the main complaint complained by the patient accompanied by other subjective and objective data which is the major data on the existence of the nursing problem.In the case above, the patient's main complaint was pain, which was then supported by other data, namely pain such as being crushed by a heavy object on a scale of 7, appearing to be grimacing in pain, pale, BP 140/90 mmHg, pulse frequency 110x/minute, respiratory frequency 24x/minute. Changes in the patient's vital signs are caused by the pain the patient is experiencing. So the patient's main nursing problem is acute pain. 3. An elderly person, 60 years old, diagnosed with DHF, was admitted to the hospital on the 1st day 3. Patients with complaints that the left hand that is connected to the IV is swollen, painful and difficult to move. Examination results: the skin around the infusion site was reddish, the infusion was not dripping, there was a blood clot in the infusion tube near the aboucat.What is the first action the nurse should take in this case? A. Shut off the infusion flow B. Remove the IV needle C. Aspirate the blood clot D. Move the IV line E. Apply a cold compress to the swollen area Answer Key: A. Closing the infusion flow. Discussion:The condition experienced by the patient in the case above was phlebitis which required the infusion to be stopped and moved to another area.The first thing the nurse must do is turn the clamp that closes the infusion flow. The next step is to open the plaster that fixes the IV tube, remove the IV catheter, apply light pressure and cover the puncture area with plaster gauze. 4. A woman, 58 years old, diagnosed with type 2 diabetes mellitus, was admitted to the hospital with complaints of sores in the buttocks area since 1 week ago. Examination results: there are decubitus ulcers, pus production (+), necrotic tissue (+). At this time the nurse will carry out wound care. The tools have been prepared, the nurse has washed her hands and put on gloves.What is the next action step that the nurse should take? A. Dry the wound B. Remove necrotic tissue C. Clean the wound with 0.9% NaCl solution D. Remove the dressing and plaster slowly E. Apply topical medication according to doctor's instructions Answer Key: C. Clean the wound with 0.9% NaCl solution Discussion:In the case above, it was explained that the nurse had carried out an assessment of the patient's wound, meaning that the bandage and plaster had been removed previously so thatpoint d isn't itthe right choice.Point CThis is the right step because before changing the dressing according to the type of wound, it is necessary to first clean the wound with NaCl or a non-toxic cleanser. 5. A man, 18 years old, diagnosed with a closed fracture of the distal 1/3 of the left femur, was admitted to the hospital with complaints of pain in the fracture area since 2 days ago. The patient said he was dizzy, his left foot felt numb. Examination results: edema in the fracture area, the tip of the left toe looks pale, CRT > 3 seconds.Is the nurse's independent intervention appropriate for this patient? A. Apply a cold compress to the edematous area B. Elevate the fractured extremity C. Observe for signs of compartment syndrome D. Observe the level of discomfort E. Massage the sole of the left foot Answer Key: C. Observation of signs of compartment syndrome Discussion:Compartment syndrome can occur in closed fractures and can cause more serious damage to muscles and other tissues, and can even result in death.Signs & symptoms of compartment syndrome: 1. Severe pain. 2. Oedema. 3. Dizziness. 4. Pale 5. Numbness 6. A woman, 53 years old, diagnosed with osteoarthritis, was admitted to the hospital with complaints of pain in both knees since 3 days ago. The patient said the pain scale was 2, stiffness in both knees. Examination results: BP 140/90 mmHg, pulse rate 78x/minute, respiratory rate 19x/minute, BMI 28.5 kg/m2(obesity). Currently the patient's condition is stable and he is being prepared to go home.Is important health education provided to this patient? A. Take analgesic medication B. Do ROM exercises C. Does not move the joint D. Cold compress on the joint E. Weigh yourself every day Answer Key: B. Doing exercises rom Discussion:1. It is important for patients with osteoarthritis to do exercises (ROM) for flexibility and muscle strength, so that the joint stiffness that the patient complains of will be reduced until it disappears. This exercise, if done regularly, will also prevent recurrence of stiff joints. 2. If the patient is stable with a pain scale of 2, treatment with non-pharmacological techniques will be recommended. 3. Not moving the joints will actually worsen joint stiffness. 4. Cold compresses are applied if the joints experience edema. 5. Weighing yourself every day is not useful if it is not accompanied by health care related to a weight loss diet in patients with osteoarthritis. 7. A man, 47 years old, diagnosed with kidney failure, was admitted to the hospital with complaints of swelling in both legs since 4 days ago. The patient said: weakness, difficulty walking, weight increased by 1 kg within 2 days. Examination results: edema in both lower extremities, oliguria, BP 130/89 mmHg, pulse rate 87x/minute, respiratory rate 18x/minute, temperature 37oC,balancefluid (+) 500 cc/24 hours.What is the primary nursing problem in this case? A. Hypervolemia B. Activity intolerance C. Body image disturbance D. Risk of being overweight E. Impaired physical mobility Answer Key: A. Hypervolemia Discussion:The patient was identified as having kidney problems (albumin 7 g/dL, BUN 20 mg/dL and creatinine 2 mg/dL). Excess fluid volume can be proven by the presence of edema in both lower extremities, body weight increasing by 1 kg within 3 days, oliguria, balancefluid 500 cc/24 hours.Edema in both lower extremities causes the patient to experience difficulty in carrying out activities. If excess fluid volume is the main nursing treatment, it is hoped that edema in both legs will be resolved so that activity intolerance, body image disturbances and physical mobility problems will not occur.