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Asked by markangel21

Read the scenario below and Describe how this new knowledge could impact your nursing practice.

 

 

At my first clinical I helped to care for an 85-year-old woman. She had vascular dementia, seizures, aphagia, DM and was actively hallucinating. She was unable to feed herself and was wanting to wonder yet couldn’t make it out of the bed. I noticed that her dementia would get aggravated if she was stimulated too much. The way I found this out was when I was feeding her breakfast. The patient in the next bed was getting physical therapy and they were pretty loud. I was trying to keep conversation with my patient to keep her distracted, but her attention was next to us. She was answering questions that were not directed at her. It got to the point where she didn’t want to eat anymore. I had to let my nurse trainer know.

Recognize and Analyze Cues

External cues- She would begin to answer the questions that were being asked to the patient next to us. She would try to leave her bed when nobody was with her, but her roommate had visitors.
Internal cues- Aggravation, confusion, loss of appetite.
Her trying to leave her bed was a safety concern. She didn’t have the strength to stand up on her own. Huge risk for falls.

make and Prioritize Hypotheses

Exacerbated dementia.
Wanting to wonder could be to try to get away from the noise.
Antipsychotic med not given.

 

Generate Solutions

Ask the group with the patient next to us to keep it down.
Look in the MAR to see if the antipsychotic med was given.

 

Take Action

“Provide a calm environment. Any extraneous noise and stimuli can be misinterpreted by the confused patient” (Wayne, 2022, “Nursing Interventions” section).
The MAR showed that the antipsychotic med was not given to her the prior day, and she was due to have the medication given to her after her breakfast.

 

Evaluate Outcomes

Once the environment was quiet and she got her medication, the patient became calm.
She stopped trying to get out of her bed.
If the patient would have gotten worse, I’m sure she would have tried to get out the bed and fallen.
Patient could have eventually had a psychotic panic due to all the stimulation and not having her meds.

Summary of the ongoing iterative process of Clinical Judgment

I believe that a thorough assessment of our patients when we receive them is so important. The nurse I was with was making her rounds and had not gotten to this patient yet. It was obvious there was something not right when we received rapport for her. She was all disheveled and laying half-way down the bed and diagonal.
Having learned what, I did with this patient, when I see another patient acting different than they should be if they are receiving treatment, I will first look at the MAR to see if they received their meds. Also, make sure to make the environment better for them until their treatment is done.

 

SCIENCE
HEALTH SCIENCE
NURSING
NUR 4153

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