Patient Data Nurses' Notes 1600 A 78-year-old frail man is admitted to a long-term care facility. Client has a history of dementia and cerebrovascular accident with left-sided paralysis. The client has limited movement on the right side, is unable to move independently, and is bedridden. Client needs assistance with all activities of daily living. Client is confused as to person, place, time, and situation. Skin is warm and dry. Client has intact skin on coccyx and heel areas. Vital signs: temperature 97.3°F (36.3°C), pulse 95 beats/minute and irregular, respirations 22 breaths/minute and regular, blood pressure 112/68 mmHg, and oxygen oximetry on room air 95%. Client has a do-not-resuscitate (DNR) order. The nurse reviews nurses' notes to prepare the individualized plan of care. Complete the diagram by dragging from the choices area to specify which musculoskeletal condition the client i most likely to experience, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. = Actions to Take Actions to Take Actions to Take Perform active range of motion on left side Provide hand rolls and ankle- foot splints E Reposition client every 2 hours. Move extremities on right side quickly and smoothly Promote negative nitrogen balance Muscle hypertrophy Potential Conditions E Arthritis Contractures E Convulsions Parameters to Monitor Parameters to Monitor Parameters to Monitor Ease of joint movement E Number of seizures Body alignment Client identification of surroundings Distance client ambulated unassisted

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