List 15 nursing interventions with rationale for Risk for Impaired Skin Integrity based on the scenario

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
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List 15 nursing interventions with rationale for Risk for Impaired Skin Integrity based on the scenario
SCENARIO 1
16/6/2021
Mrs. Dolly Sookdeo an 85-yr-old woman was admitted to ward 11 medical from the Royalty
Geriatric Home at 6.30am with a history from caregiver that patient was found slumped on
her chair with saliva drooling from her mouth just after she had eaten breakfast. She came to
hospital via an ambulance. Was seen in the A& E department, ECG was done, blood was
taken for CBC, electrolytes, LFT, RFT and RBS and an IV access was inserted on Patient's
Right wrist. Patient was seen on ward by doctor and diagnosed as Cerebrovascular Accident
(Stroke) and Hypertension. Plan of care included 1. Start Intravenous infusion 2L/24 hours
Ringers lactate alternate with 5% Dextrose Water (2) Give Aldomet 250mgs tds (3) Monitor
blood pressure q4h (4) chase blood reports (5) Give soft diet and oral fluids as tolerated.
17/6/2021. 8am.
Patient taken over awake and alert but confused and not oriented to time, place or person.
Intravenous infusion 5% D/Saline in progress. Patient unable to feed self and is taking a long
time to complete meals. Patient has difficulty speaking, and becomes very irritable and cry
while trying to communicate. She is incontinent of urine and feces, has right sided weakness
with inability to move right hand or foot, skin dry and mucus membrane (lips) dry and
cracked. Relatives claim that prior to CVA patient used a cane to assist in walking but now
patient is unable to get out of bed due to right sided weakness. Her blood pressure fluctuated
during the night shift at 6.00 am. TPR-37. 100. 20. BP 145/95.
Transcribed Image Text:SCENARIO 1 16/6/2021 Mrs. Dolly Sookdeo an 85-yr-old woman was admitted to ward 11 medical from the Royalty Geriatric Home at 6.30am with a history from caregiver that patient was found slumped on her chair with saliva drooling from her mouth just after she had eaten breakfast. She came to hospital via an ambulance. Was seen in the A& E department, ECG was done, blood was taken for CBC, electrolytes, LFT, RFT and RBS and an IV access was inserted on Patient's Right wrist. Patient was seen on ward by doctor and diagnosed as Cerebrovascular Accident (Stroke) and Hypertension. Plan of care included 1. Start Intravenous infusion 2L/24 hours Ringers lactate alternate with 5% Dextrose Water (2) Give Aldomet 250mgs tds (3) Monitor blood pressure q4h (4) chase blood reports (5) Give soft diet and oral fluids as tolerated. 17/6/2021. 8am. Patient taken over awake and alert but confused and not oriented to time, place or person. Intravenous infusion 5% D/Saline in progress. Patient unable to feed self and is taking a long time to complete meals. Patient has difficulty speaking, and becomes very irritable and cry while trying to communicate. She is incontinent of urine and feces, has right sided weakness with inability to move right hand or foot, skin dry and mucus membrane (lips) dry and cracked. Relatives claim that prior to CVA patient used a cane to assist in walking but now patient is unable to get out of bed due to right sided weakness. Her blood pressure fluctuated during the night shift at 6.00 am. TPR-37. 100. 20. BP 145/95.
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