Scenario: Mrs. Chandler is 92 years old. She is bedridden, but occasionally is up in the Geri chair. She laughs and responds to simple questions appropriately. Her medical history includes hypertension, heart failure, peripheral vascular disease; she had a cerebrovascular accident 5 years ago, and since then she has been fully dependent on activities of daily living. Mrs. Chandler can pick food with fingers but usually fed, as she has poor coordination in her upper extremities. She lives with her niece and caregiver, Ms. King, who has three children between the age of 7 and 16. The oldest child helps some by watching his great-aunt while his mother shops. Ms. King works fulltime. She double pads Mrs. Chandler while at work and comes home at lunch to provide care. Mrs. Chandler is 5′8″ and weighs 135 lb (BMI 20.52 kg/m²). The nurse flicks a cockroach off the bedsheet then examines the client. Her blood pressure is 134/88 mm Hg, heart rate is 86 beats per minute, respiratory rate is 14 breathes per minute, and her temperature is 96.2°F axillary; her oxygen saturation is 98% on room air. She has a stage 2 pressure injury coccyx measuring 4 × 5 × 2 mm, the base is pink, and the wound is surrounded by 3 to 4 mm of maceration. The house is in disrepair. There is a large hole in living room floor where it has rotted through; the hole is covered by pool table. Mrs. Chandler’s bedroom is very small, with care supplies such as under pads, dressings, and bedding stacked in corners and against the walls. There is no TV or radio in the room. A Hoyer lift is in the hallway. Her care is covered by Medicare and Medicaid.

What assessment findings that require follow-up by the nurse. Select all that apply.

1. a hole in the house flooring
2. cockroach on the client’s bedding
3. left alone for hours at a time with poor coordination in her upper extremities
4. double padding of the patient
5. Occasionally up in the Geri chair

ANSWER

Nursing Assessment Findings Requiring Follow-Up for Mrs. Chandler’s Care

Introduction

Mrs. Chandler, a 92-year-old bedridden individual with complex medical history and care needs, requires thorough nursing assessment to ensure her well-being and safety. This essay delves into the critical assessment findings that warrant follow-up by the nurse, considering her medical conditions, living situation, and caregiving arrangement.

Assessment Findings Requiring Follow-Up

1. Hole in the House Flooring
The presence of a large hole in the living room floor poses a significant safety hazard not only to Mrs. Chandler but also to her caregiver, Ms. King, and her great-nephew. The hole’s coverage by a pool table might not be adequate to prevent accidents. Immediate follow-up is essential to repair the flooring and eliminate this potential danger.

2. Cockroach on the Client’s Bedding
The presence of a cockroach on Mrs. Chandler’s bedding indicates inadequate cleanliness and hygiene in the living environment. This finding could contribute to the risk of infections, especially considering her medical conditions. The nurse should address this issue promptly to ensure a clean and sanitary living space.

3. Left Alone for Hours with Poor Coordination
Mrs. Chandler’s poor coordination, along with being left alone for extended periods, increases the risk of accidents and falls. Considering her medical history and dependency on activities of daily living, this situation is potentially dangerous. The nurse should collaborate with Ms. King to ensure appropriate supervision and assistance to prevent injuries.

4. Double Padding of the Patient
Double padding Mrs. Chandler while Ms. King is at work raises concerns about her skin integrity. It might indicate the presence of pressure injuries or the risk of developing them. The nurse should assess Mrs. Chandler’s skin condition thoroughly and educate Ms. King about proper pressure injury prevention measures.

Conclusion

Effective nursing assessment is paramount in identifying and addressing potential risks and concerns in the care of individuals with complex medical histories and care needs, such as Mrs. Chandler. The critical findings requiring follow-up, including the hole in the house flooring, cockroach presence, inadequate supervision, and double padding, must be promptly addressed to ensure Mrs. Chandler’s safety, comfort, and well-being.