Claudia Tran, age 84, has been on your skilled nursing unit following a cerebral vascular accident (CVA). Her neurologic checks and vital signs are unchanged from her baseline admission. Her CVA has impaired her ability to chew and swallow and she is receiving weekly vitamin B12 injections for pernicious anemia. She has left-sided weakness, with flaccidity of her left hand. Ms. Tran is emaciated and her skin is very fragile. She has reddened areas on her coccyx, heels, left hip, and elbows. Over the past week, Ms. Tran has become increasingly confused and incontinent. She has a gastric tube for feedings, which she receives every 8 hours. Ms. Tran constantly pulls at her feeding tube and has had to have it reinserted today after pulling it out. Because of this, a soft wrist restraint has been prescribed for the next 4 hours.
Prescribed Interventions
- Soft wrist restraint for safety for the next 4 hours (end at 1330), then reevaluate
- Vitamin B12 injection 1,000 mcg IM weekly
- Gastric tube feedings—FiberSOURCE HN 320 mL q8h
- Physical therapy daily, passive and active range of motion (ROM) as tolerated
Developing Clinical Reasoning and Clinical Judgment
- Considering Ms. Tran's condition, what special safety measures should be implemented related to the use of the wrist restraint?
- What are the risks of falling for this patient?
- Identify the risks associated with gastric tube feeding for this patient.
- Identify risk factors and preventive measures to maintain the integrity of Ms. Tran's skin.
- Identify appropriate sites and administration considerations related to the vitamin B12 injections prescribed for Ms. Tran.
Suggested Responses for Integrated Nursing Care
- Restraints are used only as a last resort after all other measures have failed. Implement alternatives to the use of restraints (refer to Chapter 4). Other measures could include placing her bed in a low position, having a family member sit with her, and placing her in a room near the nurses' station. Only use restraints as prescribed by the health care provider, and follow facility guidelines to protect the patient. Because Ms. Tran already has alterations in the integrity of her skin, pad the restraints and make sure they are the correct size. An additional safety measure would be performing frequent neurovascular checks to the extremity, including checking warmth, sensation, and capillary refill. Restraints are released at specified frequencies. This will improve the circulation to her extremities, reduce the chance of skin breakdown, and give you an opportunity to assess the site. Ms. Tran has left-sided weakness; therefore, applying a restraint on her flaccid arm could cause harm and is not needed (refer to Chapter 4).
- Ms. Tran has many factors that increase her risk for alterations in skin integrity, including decreased mobility, malnutrition, altered mental status, advanced age, incontinence, and positioning for tube feedings. A multifaceted approach is necessary to reduce her risk and prevent further alterations in her skin integrity (refer to Chapter 8). It is essential to develop a schedule for repositioning (refer to Chapter 9). Ms. Tran could benefit from a special type of mattress, such as one with a pressure-reducing surface. Implementing a physical therapy program of active and passive ROM exercises would be helpful. Arrange for a nutritional consult to ensure that she will receive adequate protein, as well as other vitamins and minerals essential to maintain skin integrity.
- What complications could result from the combination of decreased mobility and incontinence? A noninvasive way to reduce the chance of recurrent incontinence is to offer Ms. Tran a bedpan at regular intervals. Frequent skin care and use of a skin protectant/barrier to prevent damage from excessive moisture is an important part of her nursing care (refer to Chapter 7).
- Because Ms. Tran is older, confused, and in a restraint, her risk for falling is high. Keep her bed in a low position at all times and make sure her call light is within reach. Frequently check on patients such as Ms. Tran to decrease isolation, provide reorientation, and assess for patient needs (refer to Chapter 4).
- Ms. Tran is receiving tube feedings to meet her nutritional needs. Monitoring patient tolerance of enteral nutrition (EN) is part of the nursing care for patients receiving this nutritional intervention. Nursing actions that contribute to successful enteral tube feedings focus on monitoring patient tolerance of EN, patient safety, and monitoring for complications. Patient tolerance of the volume and type of formula must be monitored daily (Boullata et al., 2017; McClave, Taylor et al., 2018). Criteria to consider when evaluating patient feeding tolerance include the absence of nausea, vomiting, diarrhea and constipation, abdominal pain and feelings of fullness, and distention. In addition, the patient should have bowel sounds present within normal limits and achieve the target goal for administration of the EN. Ms. Tran is at increased risk for reflux, aspiration, and pneumonia. Make sure the patient is as upright as possible during feeding. Keep the head of the bed elevated at 30 to 45 degrees at all times during administration of enteral feedings and for 1 hour afterward to prevent these complications, unless contraindicated (McClave, Taylor et al., 2016; Roveron et al., 2018). Patients for whom semirecumbent position is contraindicated or who cannot tolerate a semi-Fowler position should be placed in reverse- or anti-Trendelenburg position (Boullata et al., 2017; Roveron et al., 2018) (refer to Chapter 11).
- When giving Ms. Tran vitamin B12 injections, use larger muscles and rotate sites. Implement the rotation schedule for this injection in her care plan. This is particularly important because Ms. Tran is emaciated and does not have good muscle mass. Avoid areas that are reddened or have palpable nodules and scars. Because vitamin B12 injections can be irritating, inject the medication using the Z-track method to minimize pain, trauma, and discomfort (refer to Chapter 5) (Taylor et al., 2023).