N109: Foundations in Nursing Practice

N109: Foundations in Nursing Practice Study Guide Risk for injury o Goal: The individual identifies possible safety issues in the home and works with the team and community resources to correct these issues. o Interventions: Work with the patient, family, and social services to identify possible safety issues in the home. Modify the home environment to remove those factors that put the patient at risk for injury. • Self-care deficit o Goal: The individual will be able to do his own ADLs and will seek help for those activities that he cannot do himself. o Interventions: Ensure that the patient knows where commonly used items are kept. Encourage the use of adaptive devices. Reinforce the need for rehabilitation and occupational therapy. • Risk for social isolation o Goal: The individual will maintain contact with all support systems and use community resources. o Interventions: Encourage the use of adaptive devices. Increase tactile stimulation and social interaction. Help the patient identify social support systems and community resources available. Provide referrals as appropriate. Implementation As interventions are implemented, the nurse must constantly reassess the individual and family to ensure that the interventions are producing the desired outcomes. Safety of the individual must be the first intervention, and the nurse must ensure that the family understands modifications that must be implemented and changes that should be reported. The nursing interventions should help to promote, maintain, and restore the patient’s sensory functioning and prevent complications. The nurse may help the family obtain needed financial and other social support, if needed. Evaluation The nurse caring for a patient with sensory impairments must continually reassess the patient and family to determine the effectiveness of interventions. The responses must be documented and shared with other health teammembers as appropriate. If the intervention was effective, it should be continued and expanded. Ineffective interventions should be altered or replaced in collaboration with the individual, family, or community. If care has been delegated to others, the nurse must be responsible for evaluating the care and effectiveness of interventions delivered by others. •

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