Elevate HOB 30 if no spinal injury May need to position on side Assist with deep breathing and use of incentive spirometer.
IMPAIRED MOBILITY Preserve proper alignment of joints and limbs. Use assistive devices such as splints and slings. Strengthen muscles. Relieve pain and muscle spasm. Hemiplegia : total or partial paralysis or loss of sensation on one side of the body. Hemiparesis : one sided weakness Quadriplegia/Tretraplegia : four limbs with loss of sensation or paralysis.
SELF-CARE DEFICIT Assist with techniques to perform self‑care. Offer encouragement. Praise any effort. Promote sense of independence and self‑esteem. Provide oral care and eye care, especially if patient is unconscious.
DYSPHAGIA Risk for nutritional disorders and aspiration pneumonia Sit upright or high fowler’s to eat and for 30 minutes after Tube feedings may be needed
INCONTINENCE Convince the nursing staff and the patient and his family that improvement is possible. Keep an accurate record of actual voiding times for a 2‑ to 3‑day period.
URINARY INCONTINENCE ASSESSMENT Difficulty in starting to void Any methods the patient uses to initiate voiding (e.g., pressure on the bladder) Degree of awareness of the need to void Ability to empty the bladder completely and amount of residual urine Signs of bladder distention and dribbling or overflow Nighttime incontinence Stress incontinence Usual times for voiding
BLADDER TRAINING PROGRAM Scheduling voiding times q 2 hrs Drink 2000 to 3000 mL of fluid before 6 pm Avoid coffee, tea, alcoholic beverages, and soda with caffeine Credé technique 6 week trial necessary to determine success
BOWEL TRAINING PROGRAM Why? Can have constipation or diarrhea Exercise program High‑fiber diet Adequate liquid intake during the day Stool softener Provide privacy
ASSESSMENT OF CONFUSION Loss of orientation to person, place, or time Inability to cooperate fully with simple tasks and requests, such as eating and bathing Inappropriate statements or inappropriate answers to questions Restlessness and agitation Hostility and anxiety Hallucinations or delusions Other signs of inability to maintain control over thought processes and behavior
APHASIA Receptive: Difficulty in interpreting written or spoken communication Difficulty receiving information Expressive: Difficulty expressing self in speech or writing Difficulty expressing information Global: Combination of receptive and expressive aphasia (Refer to Focused Assessment pg 496.)
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- Fall '19