Have you had gradual hearing loss or did it happen all at once?

Nursing Procedures and Considerations

Client Comfort and Safety

  • Nurse's Actions to Calm the Client:
    • Keep the room door wide open:
    • This may provide constant stimulation from noise at the nursing station, increasing the risk for sensory overload.
    • Reference: Williams, P. (2023). Basic Geriatric Nursing. (8th edition). St. Louis, Missouri. Elsevier. pp. 65, 184.
    • Leave the overhead light on:
    • Provides excessive light and glare, reducing the client's ability to rest.
    • Turn on the bathroom light:
    • A small amount of indirect lighting enables the client to identify the surroundings upon awakening, reducing confusion without excessive sensory stimulation.
    • Ensure the client can easily reach the call bell:
    • This safety procedure must be followed before leaving the room.
    • Ask the client if he would like music therapy or massage:
    • Provides relaxation, assisting in decreasing restlessness.
    • Reference: Williams, P. (2023). Basic Geriatric Nursing. (8th edition). St. Louis, Missouri. Elsevier. pp. 65, 184.

Burn Assessment and Management

  • Intervention for Thermal Partial Thickness Burn:
    • Cool the site with cool compresses:
    • Decreases pain, dries, and covers with a dry dressing.
    • Reference: Harding, M., et al. (2023). Lewis's Medical-Surgical Nursing. (12th edition). St. Louis, Missouri. Elsevier. p. 497.
    • Assessment for Electrical Burns:
    • Possible administration of NaHCO3 to alkalinize urine; monitor for development of myoglobinuria.
    • Hydrocolloid Dressing:
    • This is not the initial treatment for a thermal burn.

Client Teaching for Nutritional Needs

  • Feed Preparation for Clients with Diminished Taste Sensation:
    • Do not mix soft foods on the plate; it does not improve taste sensation.
    • Maintain mouth moisture:
    • Promotes taste sensation through regular oral hygiene.
    • Encourage longer chewing of food:
    • Beneficial as less chewing is required for soft foods.
    • Add seasonings to bland food:
    • Stimulates taste buds, enhancing flavor.
    • Reference: Grodner, M., et al. (2023). Nutritional Foundations & Clinical Application. (8th edition). St. Louis, Missouri. Elsevier. p. 254.

Addressing Sensory Issues in Clients

  • Teaching to Reduce Problems Related to Olfactory Sensation:
    • Encourage friends to cook meals for socialization:
    • Cooking aromas can provoke heightened sense of smell; meals should be prepared elsewhere and delivered.
    • Aromatherapy Usage:
    • May worsen symptoms for clients with a heightened sense of smell.
    • Encouragement of sniffing foods:
    • Useful for clients with diminished sense of smell.

Factors in Burn Severity Assessment

  • Factors Determining Severity of a Burn:
    • Depth of burn: Critical in assessing severity.
    • Extent of burn: Calculated in percentage of total body surface area (TBSA).
    • Location of burn: Important factor for determining severity.
    • Client risk factors: Not used to determine burn severity.
    • Electrolyte values: Important but not a factor for severity assessment as imbalances can be corrected.
    • Reference: Harding, M., et al. (2023). Lewis's Medical-Surgical Nursing. (12th edition). St. Louis, Missouri. Elsevier. p. 496.

Initial Assessment Using Rule of Nines

  • Rule of Nines Calculation for TBSA:
    • Client's hand including fingers is approximately 1% of TBSA.
    • Reference: Harding, M., et al. (2023). Lewis's Medical-Surgical Nursing. (12th edition). St. Louis, Missouri. Elsevier. p. 498.

Dealing with Client's Emotional Responses

  • Address Client's Angry Outburst:
    • Nursing Diagnosis:
    • Self-care deficit: Reflected by the fear of becoming dependent on others, impacting the performance of daily activities.
    • Understanding Client's Emotions:
    • Recognize the client’s fear of dependence and offer therapeutic responses.

Documentation and Legal Implications

  • Documentation for Heating Pad Incident:
    • Completion of Incident Report: Used to identify risk patterns; not placed in the client's chart.
    • Management of Blisters: Important to document symptoms, actions taken, and follow-ups.
    • Education about Malpractice:
    • The nurse must meet standards of care in procedures such as heat application, especially for high-risk clients.
    • Reference: Potter, P., et al. (2023). Fundamentals of Nursing. (11th edition). St. Louis, Missouri. Elsevier. pp. 337.

Home Safety Recommendations for Clients

  • Key Instructions for Home Safety:
    • Removal of rugs: Essential for preventing accidental trips and falls due to visual deficits.
    • Importance of Explaining Rationale: Increases client compliance.
    • Consultation with Eye Doctor: Unnecessary for managing throw rugs, which falls under nursing responsibilities.

Administering Medications

  • Correct Eye Medication Administration:
    • Pull the conjunctival sac down for eye drops: Avoid contact with the cornea.
    • Inner canthus pressure: Applied lightly if systemic effects are suspected.
  • Correct Direction for Eye Drops:
    • Administer two drops in the right eye every 12 hours: Ensures correct dosing.

Assessing Hearing Loss

  • Types of Questions to Assess Hearing Loss:
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