Nursing Interventions for Risk for Violence – Schizophrenia Schizophrenia is a kind of mental disorder that makes it difficult to differentiate between the real and unreal experiences, to think rationally, to have normal emotional management and to be sociable to others. Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Right heart failure Weight loss Ankle edema Abdominal distention Pain subkostal Pulsation neck region Jaundice Tired Edema, ascites Increased jugular venous pressure Complication Cardiac asthma? Each person is unique and has his own weaknesses and strengths, all of which should be assessed. Objective: Patient has a one inch laceration on the bottom of her left foot. Provide adequate lighting. Elevate the bed linen as needed Rational: a soft mattress, pillow that would prevent maintenance of proper body alignment, placing stress on the joints that hurt.
Assess for all etiologies including depression using a geriatric depression scale. Some people find alternating between hot and cold water soothing. Setting Realistic and Obtainable Goals 4. For patients who smoke cigarettes, quitting will decrease the risk of cataracts. Observation and assessment constitute skilled services when the skills of a technical or professional person are required to identify and evaluate the patient’s need for modification of treatment or for additional medical procedures until his or her condition is stabilized. Albumin A plasma protein. (The guideline for HbAlc was 200 mg/dl (11.2 mmol/l).
Provide comfort measures; encourage use of meditation and visualization. Oral care after expectoration and provide tissues and bag for disposal – promotes comfort and prevents transmission of organisms to others. Due to decreased cardiac output, there is decreased preload and stroke volume thus there is decreased blood pumped out from the blood. Cooperation with other health care team in the delivery of vasodilators, checks blood sugar regularly and oxygen therapy. Drug levels Reveal therapeutic or toxic level of prescription medications or street drugs that may affect or contribute to presence of dysrhythmias. This evidence-based study suggested leaflets as a useful resource for information provision. To ensure compatibility Obtain and record baseline vital signs Practice strict asepsis At least 2 licensed nurse check the label of the blood transfusion.
which ones? Hemoglobin is a protein in red blood cells that carries oxygen. Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration. The best way is to review the methods section of the paper for a description of how the randomisation was done and then determine whether the method ensured that patients had an equal chance of being in each group. Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures. Mary asks ‘But what if he has a fever again during the night?’ You want to understand her concerns so that you can reassure her. Mrs R’s foot wound and the exposed tendon are dry, therefore, a dressing that hydrates the wound-such as a hydrogel-should be used.
Make sure patient does not neglect affected side; provide assistive devices as indicated. Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion. Stop the transfusion immediately, and notify the physician. Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous client. Send the blood bag and tubing to the blood bank for repeat typing and culture. Assist the client with limited mobility to obtain evaluation for a physical therapist and to obtain assistive devices as indicated (Maloney, Cafiero, 1999); assist the client to select shoes with a nonskid sole to maximize traction when arising from a chair and transferring to the toilet. Collect a urine sample as soon as possible for hemoglobin determination.
Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria. Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions. In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed. R/ : Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998). (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.) For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed. Nursing Interventions If blood transfusion reaction occurs: STOP THE TRANSFUSION. Start IV line (0.9% NaCl) Place the client in Fowler’s position if with Shortness of Breath and administer O2 therapy.
The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Notify the physician immediately. Touch helps with integration and fosters social relatedness. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis. 4. Evaluation The patient maintains normal breathing pattern. The patient demonstrates adequate cardiac output.
The patient reports minimal or no discomfort. Of these 13 physicians, 9 strongly recommended that the program be adopted by their health care system. The patient remains normothermic. The patient remains free of infection. The patient maintains good skin integrity, with no lesions or pruritus. The patient maintains or returns to normal electrolyte and blood chemistry values.