Using the above scenario, complete the Water-low chart (available on the Health noticeboard).
Using the above scenario, complete the Falls Risk Assessment tool (available on the Health noticeboard).
a) List two interventions you documented as applied to this client in the Waterlow
and one from the Falls Risk Assessment Tool. (Giving a total of three interventions) (Referencing is not required for this question)
b) Explain the Rationale (or objective) for each intervention listed above. (Three required). In other words what are you (the nurse) trying to achieve with the application of that intervention. (each Rationale needs to be referenced)
Give examples of how the following would be assessed/ evaluated following in relation to the interventions given above.
a) Skin Integrity (at least 6 points)
b) Weight (at least two types of assessment that involve this)
c) Musculoskeletal system (two tools you could use- which are ambulation related)
A Registered Nurse asks you a first-semester student to give a patient a medication.
What is your response?
Explain three essential points of the decision-making framework that you must consider in this process and how they related to your decision.
Mrs Volk is planning to be discharged back home after this current admission. In regards to her ability to mobilise three questions you might ask are listed below- use the table to answer this question.
State why we ask this question and how this information is used to decrease her chance of falling when she is finally discharged home.. – Use your client Vonnie Volk to help you answer your questions and state what services you would need to discuss with her, refer her to, and put in place for her.
As noted in this scenario earlier- Mrs Volk has moderate confusion forgetting the date, time and where she is, but is aware of the correct details when asked questions regarding herself. As a results of this she is being assessed to ascertain whether she has Dementia, Delirium or Depression.
Give three signs or symptoms which would indicate this client has Dementia and not
Delirium or Depression.
When assessing for Dementia a doctor may ask the nurse to perform tests such as a Urinalysis. This is to exclude a possible Urinary Tract Infection as a possible cause of the client’s behaviour.
a) Name three results on the dip stick that may indicate a urinary tract infection.
b) Name two other standard tests a nurse does to observe the client for signs of other illnesses which may cause confusion?