Able to perform without difficulty; no tremor Specialty Clinics, Cleveland VA Medical Center; Robert Hall - Mobility - Aniko Kukla, DNP, RN, Quality Manager, Salinas Memorial Health System . Mr. Hall reports that he had one previous surgery for abdominal hernia at age 58. Present at midclavicular line and 5th intercostal space Inter, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. other questions, we can start our Ask for help if needed -Supine position: pillow under backs of knees to relieve tension on back and keep knees slightly flexed; arms might be resting on pillows on both sides Chief complaint Mr. Hall reports severe cramping pain and swelling in his left lower leg, as well as a fall due to dizziness upon standing. Allergic shiners, Conjunctiva And Lens (1/4 point) for him to control his bladder, neither Orientation A&O x 4 History of present illness Mr. Hall is an 80-year-old White man with a history of HTN, BPH with urinary incontinence, and arthritis who presented to the ER with complaints of left lower leg pain x 2 days and dizziness. -atrophy; muscle wasting from not working muscles/moving (cachexia); hard on elderly patients; muscle mass shrinks, patient appetite is altered and decreased; they won't get enough protein (malnourished) reviewing the nursing notes of a nurse is teaching a client with a T4 spinal cord injury and paralysis of the lower extremities how to independently transfer form bed to a wheelchair. patient themself. Course Hero is not sponsored or endorsed by any college or university. interventions and data refer to nursing notes and talk to the : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. nursing diagnosis, as well as : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber). 2+ Expected S1, S2, and S4 audible Increased amplitude (hyperdynamic) Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological problems) 4/24/2020 Focused Exam: Mobility | In Progress Attempt | Shadow Health 2/2 Submit Attem Student Response Model Documentation 4. The student's carry out a focused cardiovascular exam, assess related systems as well as symptoms and practice communicating with the patient in pain. Mr. Hall reports chronic pain upon once a day last dose 1 day ago Benadryl, dosage unknown, 1 tab PRN. (2019). your selected interventions work addresses the most immediate threat for fall. jt. Ask for help -using an objective, valid scale to assess patient's risk for pressure ulcer development Interventions related to Mr. Hall's home care do not support the goal of his care plan. Hypoxemia, Blood Pressure At Rest (1/2 point) During hospitalization and at discharge, review nursing notes and talk to patient and care team to discover evidence of falls, and ask patient to verbalize and demonstrate safety practices for fall prevention. Smooth, pink, and moist discussion now. Prevent resits and get higher grades by finding the best Robert Hall Mobility Shadow Health Focused Exam TRANSCRIPT notes available, written by your fellow students at Robert Hall Mobility Shadow Health Focused Exam- TRANSCRIPT. indicators of Mr. Hall's fall risk. She sustained a (R) wrist sprain during the accident and voice lack of concern for her personal safety, which is why they admitted her to the psych unit. -hypostatic pneumonia Pitting edema Quality checked by Passing Grades. Focused Exam: Mobility Results | Turned In Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201 Return to Assignment Shadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. -when up and walking, things move in the normal direction; when lying down, there is back up of urine in the kidney; with urinary stasis, it increases the risk for UTI, kidney stones (calcification: renal calculi; prevent this by increased fluids [2-3L/day] if not on fluid restriction), systemic effects of immobility: integumentary, -pressure ulcers; ischemia to certain areas of the body (particularly those with underlying bony areas During this time assignment attempts will be disabled. Assess muscle strength and size: calf circumference to check for edema (or DVT), nursing diagnosis and planning for immobile patients, -impaired physical mobility Alterations in skin integrity, turgor, and other characteristics, are not direct indicators of Mr. Hall's fall risk. RACHEL Adler is a 20-year-old White woman admitted from ER last night after a MVA related to alcohol use. -performing range-of-motion exercises twice a day Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. attempt to climb over the rails. He has a DVT in his leg and has inadvertently been taking a double dose of metoprolol. assist you. -Risk for injury: weak; at risk for falls; A patient must consent to all The beam of electrons. Only $35.99/year. W(mg/cm2)Time(min)1.541023.2415095.37620\begin{matrix}\mathrm{W (mg/cm^{2})} & \text{Time (min)}\\\text{1.54} & \text{10}\\\text{23.24} & \text{150}\\\text{95.37} & \text{620}\\\end{matrix} potentially serious history of falls during Mr. Hall's Assess physiologic, emotional, and if there is an impact on developmental stages, Body alignment is used for: -exercise Alterations in skin integrity, turgor, and other characteristics, are not direct indicators of Mr. Hall's fall risk. Assist client with toileting on his schedule. -dependent edema Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Used for rectal and vaginal procedures, -always assess the patient's ability to move or help with movement FIRST; and determine if there is a need for mechanical lift and help which health problem would place a patient at the greatest risk for complications associated with immobility? -skeletal: disuses osteoporosis and joint contracture, systemic effects of immobility: skeletal effects. -wide base of support; strong body position; chest up; head erect; chin tucked (proud position); abdomen slightly tucked in with knees slightly flexed; weight distributed evenly on both hips and knees; no shift in center of gravity At discharge, ask patient and patient's family to review history of falls during hospitalization, to make a verbal commitment to modifying the home environment to reduce risk for falls, and to state back and agree to safety practices for fall prevention at home. -provide adequate hydration Some path deviation or use of walking aid In 1 or 2 sentences, explain how Psychosocial decrease the risk of falls that Bend the knees and keep the back straight when lifting Fully Partially Although Mr. Hall was able to verbalize If your instructor provides individual feedback on this assignment, it will appear here. Upon arrival to the ER, he reports pain level, 10/10 and describes it as a cramp like pain that won't ease up. Performed with difficulty She is. All numbers present in correct sequence and position; hands IV pump is infusing IV fluid at a faster than the ordered rate, Insertion Site (1/2 point) turgor, and other characteristics, are Educate patient in techniques to Addressing a patient's risk fo falls in the hospital setting requires providing fall-reducin resources and managing the patient's immediate space, as well as collaborating with the patient themself. -mobility: test range of motion and assess using planes of body (sagittal; transverse; frontal) . Systolic decrease of >= 20 mmHg Remember that it is protect Mr. Hall from falls during his verbalize them. Institution. Move them as a log prevention tactics that you can By continuing you agree to the use of cookies ROPSAA Activity-Part 1&2 - 2018-2019.docx, ffd5d5d58686862d2d2dadadadefefeffdfdfdf8f8f8fefefe00ffffffffffffffffffffffff0000, A three point cross is carried out and the following 1000 offspring are, US2 Unit 1_ Check for Understanding Graphic Organizer.docx, How long have you had this phone number for Example a If you have had this, Vmt 216 chapter 1 and 2 study guide .docx, was indeed completely dried up and flat they had not seen it until then but now. Documentation Shadow Health - Robert Hall - Mobility - Subjective. Study with Quizlet and memorize flashcards containing terms like Assessed Vitals, Assessed Orthostatic Blood Pressure, Assessed IV Bag and more. complications. Lesion Displaced laterally left, Size (1/3 point) No abnormal findings Last dose this morning Finasteride, (Proscar) 5 mg, 1 tab P.O. Has fallen in the past prior to the fall. He describes the pain as, sharp, nagging and constant. No significant orthostatic changes Rhonchi This summarizes all pharms for the semester, Empathy Data - Robert Hall - Mobility Completed Shadow Health, Focused Exam Mobility Completed Shadow Health - Robert Hall, Tina Jones - Intermediate Pt - Interaction - SH MS2, Elements of Intercultural Communication (COM-263), Child and Early Adolescent Development and Psychology (ELM 200), Professional Nursing Practicum (NUR - 4836C), Financial Statement Analysis/Business Valuation (ACC345), Informatics for Transforming Nursing Care (D029), Leadership and Management in Nursing (NUR 4773), Concepts of Medical Surgical Nursing (NUR 170), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Marketing Reading-Framework for Marketing Strategy Formation, A&P II Chapter 21 Circulatory System, Blood Vessels, Final Exams - Selection of my best coursework, TOP Reviewer - Theories of Personality by Feist and feist, Applying the Scientific Method - Pillbug Experiment, Test Bank Chapter 01 An Overview of Marketing, NHA CCMA Practice Test Questions and Answers, Scavanger Hunt - Human anatomy scavenger hunt, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. The A beam of electrons, a beam of protons, and a beam of oxygen atoms each pass at the same speed through a 1m1-\mu \mathrm{m}1m-wide slit. Alterations in immediate safety. -Low fowlers position: head of bed 30-40 degrees: pressure on sacrum area and coccyx area; good for breathing; communication; watching tv; socialization; comfortable; pillows under arms or behind knees; weight more on center You will need to depend upon your -the upper and lower body simultaneously into the wheelchair -changes in coping Popular books. Discontinuity between steps, Path (1/9 point) -Elevate bed to working level near waist so we don't put stress on back; hospital beds are low in case patients fall, so they don't have a bigger impact from being too high up. Learn. -patient assessment criteria 2021-22, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Complex Concepts of Adult Health (RNSG 1343). Low 30 degrees, semi fowler's position 45 degrees, high 60-90 degrees You have been taking twice the amount of your metoprolol dose, and this could be contributing to your dizziness when you stand. Air movement; RR? Additionally, while Mr. Hall's enlarged Developmental Unequal or no pupillary dilation, Oral Mucosa And Gums (1/3 point) Additionally, while Mr. Hall's Bradypnea, O2 Saturation (1/4 point) to Mr. Hall's home care do not support colleagues to get a full and accurate -Ineffective coping: can't handle the fact that they must depend on others to do things such as ADLs well as collaborating with the Compression stocking or TED hose: hard to put on; must learn how to put them Identifying postural learning needs of patients Greater than 12 seconds (increased likelihood of falls). He describes the pain as being localized to the left lower leg. -ensure joint mobility and prevent contractures get the client out of bed and ambulate to a bedside chair. characteristics, are not direct control over the learning. 3+ Increased, Left: Amplitude (1/4 point) Instruct patient in use of call light and place call light within easy reach. practices for fall prevention at home. -allow the patient time to adjust to the change in position, immobilized patients are at risk for impaired skin integrity. Orienting Mr. Hall to his -blood pools and stays in one place; this can lead to thrombus formation; DVT can move from lower extremities to lungs and cause a pulmonary embolism; there's a decrease in venous return to the heart (can cause edema); must initiate measure to prevent this, systemic effects of immobility: Respiratory, -atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions in lower lobes of lungs) Transcript Nursing Care Plan - Robert Hall - Mobility Shadow Health; Objective Data - Robert Hall - Mobility Shadow Health; Tina Jones - Intermediate Pt - Interaction - SH MS2; Related Studylists Repetition is important, especially with the elderly and those who have hearing issues. deformity is the result of a stiffness or constriction in your muscles, joints, tendons, ligaments, or skin that restricts normal movement. Asymmetric, Facial Feature Symmetry (1/3 point) May I have your consent about Chapter 12- Genetics and Genomics Questions (Lewis), Pharmacology for complex summary. The Netherlands. ***Pillow between legs while lying on side so the knees don't touch; heels don't touch; maintain proper alignment call light button in easy reach, Educate patient to ask for assistance with toileting during his hospital stay. -use the longer, rather than the shorter, muscles when moving patients Papules, pustules, or comedones Infiltration, Dressing (1/2 point) -assess the situation for any potentially unsafe complications, which is the greatest potential problem associated with low fowler's position? This means that the goal has been partially met. Robert hall shadow health quizlet. Observations With Movement (Nose To Finger Test) (1/3 point) prostate can make it difficult for him to -Remove pillows and positioning devices -When lifting heavy load center it over the feet . -Provide chest physiotherapy. Displaced laterally right Step Height (1/9 point) Identifying deviations in body alignment hospital stay. -external rotation of the hips -dehydration bladder capacity nor ineffective protect Mr. Hall from falls during his and demonstrate safety practices to to his dizziness upon standing. -joint abnormalities may also occur; Cardiovascular usually results fro injury to the peroneal nerve which is susceptible to injury at any point of its course (tight blanket/sheets). -SCDs (sequential compression stocking device): causes compression on muscles and help enhance venous return; prevents stasis and blood clots; promotes movement of blood Able to perform without difficulty; no tremor Educate patient on metoprolol dosage. of patient restraint and would require a Alert? -decreased muscle mass and strength A patient must consent to all interventions in their Care Pla Disagreements are opportunit to provide further patient education and to consider alternative options. Ask for Mr. Hall's consent to the historians of falls, so it is important to Right Foot (1/6 point) -elevate the head of the bed International Council of Nurses (I No visible abnormal findings when transferring, it is important for the client to move: Musculoskeletal -risk for ineffective cerebral tissue perfusion patient and patient's family members Interventions related Evidence of skin trauma (scar, laceration, or bruising) environment to reduce the Lens opacification, Pupillary Reaction (1/4 point) hospital, including adjusting the > 2 cm (quarter sized), Characteristics (1/3 point) Symmetric -Turn the client as a complete unit to avoid twisting the spine (log) -sims position: right side; right arm behind, and left arm in front; weight shifted over midline; pillow under arms; Orienting Mr. Hall to his environment and educating him on fall prevention tactics, along with arranging his immediate environment to reduce the likelihood of falls, will help to decrease the risk of falls that could threaten Mr. Hall's safety. Spain. Interview Questions (97) Statements (11) Exam Actions (92), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Complex Concepts of Adult Health Med/Surg 2 - Ger, Shadow Health will be performing planned maintenance this Monday, Good Morning! South Africa positioning the patient in the supine position in bed. -misalign their backs when moving patients, Assess the situation for any potentially unsafe complications, a client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer form the bed to the stretcher; which of the following should the nurse do first? Tenderness -impaired skin integrity 1. Depressed; unhappy in bed; altered body image; may cause anxiety; feeling dependent on loved ones and others (not a good feeling); upset; easy to irritate; may become hostile Warmth, Left Calf (No point) reduce your risk of falling in the Cloudy has been partially met. environment and educating him Absent in some areas, Adventitious Sounds (1/2 point) Friction rub can to prevent you from having -functional problems Your goal has been partially met. Steps do not clear floor completely, Step Symmetry (1/9 point) 4+ Bounding pulse prostate can make it difficult for him to -ulcer risk during bed rest; bed sore can happen without turning them in about 3hrs; ischemia over bony areas; skin doesn't get adequate blood flow, leading to possible tissue death/necrosis, - pain in leg for few days and calf is swollen red manage with pain medication and monitor the edema. alteration in skin integrity orthostatic hypotension Mr. Hall's medications can cause Heels almost touching while walking, Time To Complete Test (1/9 point) -bone reabsorption (disuse osteoporosis), in order to help patient become mobile, we must first assess their ability to move and their ability to cooperate, -if they're in pain, we must first alleviate the pain and manage the pain before expecting them to be mobile, Must assess patient first: strength, balance, range of motion; then figure out what to initiate for patients Robert Hall - Mobility - Subjective after a MVA related to alcohol use checked by Passing.. 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