N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

5.10 Nursing Procedures Nursing Diagnosis • Impaired physical mobility related to prolonged bedrest. • Activity intolerance related to sedentary lifestyle. • Impaired skin integrity related to increased pressure over bony prominences. • Risk for injury related to unsteady gait. Evaluation • Record and report the patient’s response. Document color and condition of the skin, development of pressure areas, performance of ROM exercises, independent ambulation, and participation in regular exercise routines. • Reassess and revise the plan of care when necessary. Turn and reposition the patient more often. Select a device to minimize pressure. Teach the patient how to keep weight off pressure areas. Revise the teaching plan as needed. • Determine the patient’s response to care of other health care team members. Ask the LPN to report any patient mobility problems. Ask the NA to describe changes in skin conditions due to restricted mobility.

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