A practical nurse (PN) responds to a call light and finds an older adult client with age-related presbycusis and diminished visual acuity attempting to climb over the bed rails. The client, who is currently hospitalized for pneumonia, appears restless and states they need to go look for their spouse. Arrange the following practical nursing actions in the priority order they should be implemented. (Place the highest priority action first.)
- 1Guide the client gently back to a safe resting position in the bed.
- 2Turn on the room lights and speak distinctly while facing the client.
- 3Obtain current vital signs and oxygen saturation levels.
- 4Reorient the client verbally to the hospital environment and situation.
- 5Report the acute mental status changes to the supervising registered nurse.
Cevap
The correct priority order is to first secure physical safety, then accommodate sensory changes, collect physiological data, provide cognitive reorientation, and finally report the findings.
In an older adult client exhibiting sudden confusion and unsafe behavior, the first priority according to the nursing process and Maslow's Hierarchy of Needs is immediate physical safety (preventing a fall). Next, the nurse must accommodate age-related sensory deficits (presbycusis and vision changes) by improving lighting and communicating clearly, which helps de-escalate the situation. Once the client is safe and calm, the nurse collects physiological data (vital signs and oxygen saturation) to rule out physical causes of delirium, such as hypoxia from pneumonia. After data collection, therapeutic cognitive reorientation can be attempted. Finally, the nurse reports the acute changes and assessment data to the supervising RN for further evaluation and intervention.
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Anahtar Kavram
Prioritization of safety, sensory accommodation, and physiological assessment during acute delirium in older adults.