Question

Chapter 4 - Go to Clinical Case Nurse Think Concept: Movement, Sensory, Nerve Conduction: Mobility After reviewing this "Go to Clinical Case" and the corresponding Concept Map use Nurse Think and complete this challenge. Ana Patterson is a 94-year-old who lives in Nurse Think Healthcare Long Term Care Home. She has had Alzhel- mer's disease for 5 years. Other past medical history includes hypertension, osteoarthritis, depression, and a history of falls at home prior to being admitted to the long-term care home 4 years ago. The unlicensed assis tant personnel (UAP) staff have noted that Ana is requiring more care because she is not sleeping at night and is consistently calling out for her husband who has been deceased for 10 years. Normally Ana is able to walk unassisted in the hallways, but in the last week, she has been found on the floor three different times without injuring herself. The UAP is encouraging Ana to sit in a chair during the day but she is not staying seated even during meals. She often gets out of bed alone during the night Next Gen Clinical Judgment Challenge-For Each student 1. What are the Top 3 priority assessment or cues for Ana? 2. What are the Top 3 priority nursing actions for Ana?

Answer 1

1. Top three priority assessment for Ana are :-

- Neurological assessment

- Psychiatric assessment

- Musculoskeletal assessment

2. Top three priority nursing actions are :-

- Don't leave the patient alone , one healthcare workers should be always with her .

- Keep the side rails up of the bed

- Providing psychological and emotional support to the patient .