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Difficulty: MediumAccident, Error, and Injury Prevention

A home health nurse is establishing a plan of care for an older adult client who recently experienced a right hemisphere stroke, resulting in left-sided hemiplegia, unilateral neglect, and mild dysphagia. Which of the following safety interventions should the nurse include in the care plan? (Select all that apply.)

  1. Place frequently used personal items and the call button on the client's right side.Answer
  2. Ensure the client remains seated in an upright, high-Fowler's position for at least 30 minutes following meals.Answer
  3. C
    Direct the nursing assistant to determine if the client is pocketing food during meals.
  4. Fasten a transfer belt securely around the client's waist prior to assisting them out of bed.Answer
  5. E
    Place the wheelchair on the client's left side when performing a stand-pivot transfer.
  6. F
    Request a prescription for physical restraints to prevent the client from getting up unassisted during the night.

Answer

The correct safety interventions to include in the care plan are placing personal items on the client's right side, maintaining a high-Fowler's position for at least 30 minutes after meals, and utilizing a transfer belt before assisting the client out of bed.
The correct safety interventions directly address the client's specific neurological deficits. Placing items on the strong right side accommodates hemiplegia and unilateral neglect, preventing falls caused by leaning or overreaching. Maintaining a high-Fowler's position post-meals protects the airway of a client with dysphagia from aspiration. Using a transfer belt provides necessary stabilization for a hemiplegic client during mobility tasks.

Step-by-Step Solution

1
Identify the client's specific physical and cognitive deficits from the clinical scenario.
The client presents with left-sided hemiplegia, unilateral neglect, and mild dysphagia.
Safety interventions must be individualized and tailored to the client's specific functional limitations to be effective.
2
Evaluate each proposed safety intervention against the identified deficits.
Interventions must accommodate the unilateral weakness, protect the airway, and avoid placing unsafe physical demands on the affected side.
Applying standard safety measures without considering individual neurological deficits can inadvertently lead to patient injury.
3
Select the interventions that safely address the client's needs while adhering to nursing standards.
Placing items on the right side, maintaining a high-Fowler's position post-meals, and using a transfer belt are identified as safe and appropriate.
These actions directly mitigate the risks of overreaching falls, aspiration, and transfer-related injuries without violating care protocols.
4
Identify and exclude interventions that are unsafe or violate nursing scope of practice.
Delegating swallowing evaluation to a UAP, placing the wheelchair on the paralyzed side, and using restraints as a primary safety measure are excluded.
These actions either increase the physical risk of injury or violate the RN's core responsibility for clinical assessment and least-restrictive care.

Key Concept

Accident, Error, and Injury Prevention in Stroke Rehabilitation
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Topics

Accident, Error, and Injury Prevention

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