Cancer disorders: Planning discharge teaching for a client who is postoperative following a modified radical mastectomy-AMS Chapter 92
• Modified
... [Show More] radical mastectomy: lymph nodes removed
• Nursing Actions:
➢ Have the client sit with the head of the bed elevated 30° when awake and support her arm on a pillow. Lying on the unaffected side can relieve pain.
➢ Have the client wear a sling while ambulating (to support arm).
➢ Avoid administering injections, taking blood pressure, or obtaining blood from the client’s affected arm. Please a sign above the client’s bed regarding these precautions.
➢ Emphasize the importance of well-fitted breast prosthesis for a client who had a mastectomy.
➢ Provide emotional support to the client and her family
➢ Encourage the client to express feelings related to perception of sexuality and body image.
• Client education:
➢ Teach the client how to care for her incision and drainage tubes (drains are usually left in for 1 to 3 weeks)
➢ Advise the client to avoid placing her arm in a dependent position. This position will interfere with wound healing.
➢ Encourage early arm and hand exercises (squeezing a rubber ball, elbow flexion and extension), and hand-wall climbing to prevent lymphedema and to regain full range of motion
➢ Teach the client not to wear constrictive clothing and to avoid cuts and injuries on the affected arm.
Continuity of care: Interventions promoting independence- CH Chapter 7
• Community health nurses play a large role in maintaining continuity of care for clients as they transition from acute to outpatient settings and promote independence.
• Group partnering to elicit needed change in the community are more powerful than a nurse working independently with an individual.
• Nursing interventions:
➢ Initiate necessary consults, or notify the provider of the client’s needs so the provider can initiate a consult.
➢ Seek expertise from health care professionals representing a variety of disciplines.
➢ The nurse educates clients about community resources and self-care measures
➢ Coordinate all health care services and resources.
Crisis management: Crisis intervention for intimate partner-MH Chapter 29
• A crisis is an acute, time-limited (usually lasting 4 to 6 weeks) event during which a client experiences an emotional response that cannot be managed with the client’s normal coping mechanisms.
• Maturational/internal crisis: Achieving new developmental stages, which requires learning additional coping mechanism
• Crisis intervention is designed to provide rapid assistance for individuals or groups who have an urgent need
➢ Promote a sense of safety by assessing the client’s potential for suicide or homicide
➢ Identifying the current problem and directing interventions for resolution
➢ Helping the client to set realistic, attainable goals
➢ Strategies to decrease anxiety
➢ Critical Incident Stress Debriefing is a group approach that can be used with a group of people who have been exposed to a crisis situation
Facility protocols: Discovering a medication error- Leadership Chapter 5
• Incident reports are records of unexpected or unusual incidents that affected a client, employee, volunteer, or visitor in a health care facility. In most states, as long as proper safeguards are employed, incident reports cannot be subpoenaed by clients or used as evidence in lawsuits.
• Medication errors, procedures/treatment errors, equipment-related injuries/errors, needle stick injuries, client falls/injuries, visitor/volunteer injuries, threat made to client or staff, loss of property.
• In the event of an incident that involves a client, employee, volunteer, or visitor, the nurse’s priority is to assess the individual for injuries and institute any immediate care measures necessary to decrease further injury. If the incident was client-related, notify the provider and implement additional tests or treatment as prescribed.
....................................................................................................................................................................................................CONTINUED [Show Less]