NCLEX-PN

●​ Collaboration : Work with a multidisciplinary team, including wound care specialists and physical therapists, to develop and implement a comprehensive plan for skin integrity. ●​ Documentation : Record the repositioning schedule, skin assessments, interventions performed, and outcomes in the client's medical record. Evaluating Client Responses to Immobility Prevention Interventions The nurse plays a critical role in assessing and evaluating the client's responses to interventions aimed at preventing complications from immobility. By closely monitoring the client's progress, the nurse can determine whether the expected outcomes have been achieved. Here are the specific aspects that the nurse evaluates: ●​ Active Range of Motion : Assess whether the client is able to perform an active range of motion exercise on all joints as prescribed. Evaluate the client's joint mobility and any improvements in joint function. ●​ Safe Transfers : Observe the client's ability to transfer safely from the bed to a chair with assistance. Look for signs of discomfort, pain, or difficulty during the transfer. ●​ Venous Stasis : Monitor the client for any signs of venous stasis, such as edema, discoloration, or swelling in the lower extremities. Evaluate whether preventive measures have been successful in promoting circulation. ●​ Deep Breathing and Coughing : Assess the client's ability to demonstrate proper deep breathing and effective coughing techniques. Look for improvements in lung expansion and the ability to clear respiratory secretions. ●​ Ambulation and Physical Activity : Evaluate whether the client can successfully ambulate 30 feet three times a day with assistance and a walker. Observe any improvements in mobility, strength, and coordination. ●​ Assistive Device Use : Determine whether the client is using their assistive device correctly while ambulating. Ensure that the client is safe and confident in using the device. ●​ Skin Integrity : Inspect the client's skin for any signs of breakdown, redness, or pressure ulcers. Evaluate whether the interventions have effectively prevented skin integrity issues. ●​ Respiratory Function : Monitor the client's respiratory status, including breathing patterns and oxygen saturation levels. Assess improvements in lung capacity and overall respiratory function. ●​ Overall Comfort and Well-Being : Communicate with the client to gather feedback on their comfort level and overall well-being. Address any concerns or challenges they may be experiencing. Evaluation Process ●​ Assessment Data : Review the initial assessment data and compare it to current observations and measurements.

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