1. Physiological Integrity: Basic Care and Comfort Ms. Kristine DeBarge

2. Assistive Devices: Collaborative Care Determine ability to bear weight per MD order Monitor need for gait belt Ensure use non-skid socks/shoes Monitor for orthostatic hypotension Maintain environment free of clutter May include: feeding devices, telecommunication devices, touch pad, communication board Review correct use with client PT consult

3. Crutches Correct fit –Check correct fit 2-3 finger-widths from axilla –Position hands with elbows flexed Non-weight Bearing/Weight Bearing Walking up Stairs –“good goes to heaven” Walking Down Stairs –“bad goes to hell”

4. Cane To size have client wear shoes Cane used “unaffected” side Advance with affected leg “Unaffected” leg = 1 st full weight-bearing step on level surfaces COAL = Cane Opposite Affected Leg

5. Walker Have client wear shoes for proper size –Wrists even with handgrips on walker when arms dangled downward Advance walker 12” with affected leg then unaffected leg Wandering Wilma is Always Late = Walker With Affected Leg

6. Elimination Identify risk for impaired elimination (i.e. medication, hydration status, etc.) Institute bowel and bladder management Monitor bowel sounds Measure intake & output Perform irrigation as needed (i.e. urinary, bladder, etc.) Perineal care Provide skin care to client who is incontinent –Use barrier cream prn

7. Mobility/Immobility Signs/symptoms venous insufficiency –Promote venous return Elastic stockings (TED hose) Sequential stockings Assess mobility, gait, strength, motor skills –Assist as needed Ambulation ROM Transfers Repositioning Use of adaptive equipment

8. Mobility/Immobility Help client maintain mobility –Active/passive ROM –Strengthening –Isometric exercises Maintain skin integrity Maintain correct alignment

9. Immobility Problems Pressure Ulcers External rotation of hip Foot drop Contractures Bowel and bladder dysfunction Hypostatic pneumonia Stasis of secretion Muscle atrophy Venous thrombosis Psychological deterioration 9

10. Pain Data Collection –Type of pain Acute Chronic Intractable –Location Anatomic location Radiating Migrating 10

11. Pain Quality of pain (description) Intensity on 1 to 10 scale Onset and precipitating factors Aggravating factors Associated factors Alleviating factors Client’s behavioral response 11

12. Pain Implementation –Reassure –Distraction –Comfort Measures (position, elevation, heat/cold, etc.) –Massage –Pain medication –Alternative controls (TENS, blocks, surgical procedures) 12

13. Non-pharmacological Comfort Interventions Assist client with visual or auditory impairment Use of alternative/complementary medicine (i.e. music therapy) Respect client palliative care choices Reinforce client teaching on stress management –Relaxation –Exercise –Meditation

14. Nutrition and Oral Hydration Identify risk for aspiration (i.e. feeding tube, sedation, post-op, swallowing difficulties, etc.) –Assess client ability to eat –Check feeding tube for patency Provide nutritional needs of client Assess impact of client disease/illness on nutritional status Monitor intake/output

15. Nutrition and Oral Hygiene Client teaching on special diets (consider diet/nutrition needs/cultural considerations): –High protein –Kosher diet –Calorie restriction –Low residue –High fiber –Low sodium

16. Personal Hygiene Determine usual habits/routine Assist with activities of daily living prn Reinforce client teaching on adaptations needed for ADL’s (i.e. shower bars, seat, etc.) Assist with post-mortem care prn

17. Rest and Sleep Identify usual habits/rituals for rest and sleep Provide measures to promote sleep and rest –Back rub –Quiet environment –Turn out light Schedule activities to promote sleep and rest

18. Questions?