Acute Care Case Study
4. Mr. Ochoa will spend several days hospitalized in the acute care setting as he is stabilized and treated for CVA List nursing interventions as they relate to the CVA patient for the following areas of concern. (Acute care: prevent further injury and addressing current issues)
Mobility: (3)
List three nursing interventions aimed at preventing immobility related issues while in the acute care setting.
1. Never pull on the affected extremity when moving patient.
2. Encourage continuous shoulder movement, elevation of the arm above the heart, and regular fist clenching exercises.
3. Encourage active and passive ROM to improve and maintain muscle tone.
Safety: (3)
List three safety interventions aimed at protecting the patient while in
the acute care setting
1. Encourage client to use call light and request assistance whenever needed.
2. Identify clients that are likely to fall by placing a "Fall Precautions" sign on the doorway and by noting the chart.
3. Maintain a safe environment by removing unnecessary furniture/ décor and clear walkway areas.
Elimination: (3)
List three interventions aimed at managing urinary and bowel elimination while in the acute care setting. 1. Perform intermittent sterile catheterization during periods of loss of bladder control.
2. Analyze voiding pattern.
3. Offer urinal or bedpan on patient’s voiding/defecation schedule.
Skin Integrity: (3)
List three interventions aimed at treating and preventing integumentary issues while in the acute care setting.
1. Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection.
2. Pay special attention to high-risk areas such as bony prominences, skin folds, sacrum, and heels.
3. Minimize exposure of skin impairment and other areas to moisture from incontinence, perspiration, or wound drainage.
Comfort/Rest/Emotional Care: (3)
List three interventions aimed at providing comfort, rest, and emotional care while in the acute care setting.
1. Assess client’s level of comfort on a consistent basis.
2. Provide a judgment free environment, with acceptance and support.
3. Arrange situations that encourage autonomy.
Mobility: (3)
List three nursing interventions aimed at preventing immobility related issues while in the acute care setting.
1. Never pull on the affected extremity when moving patient.
2. Encourage continuous shoulder movement, elevation of the arm above the heart, and regular fist clenching exercises.
3. Encourage active and passive ROM to improve and maintain muscle tone.
Safety: (3)
List three safety interventions aimed at protecting the patient while in
the acute care setting
1. Encourage client to use call light and request assistance whenever needed.
2. Identify clients that are likely to fall by placing a "Fall Precautions" sign on the doorway and by noting the chart.
3. Maintain a safe environment by removing unnecessary furniture/ décor and clear walkway areas.
Elimination: (3)
List three interventions aimed at managing urinary and bowel elimination while in the acute care setting. 1. Perform intermittent sterile catheterization during periods of loss of bladder control.
2. Analyze voiding pattern.
3. Offer urinal or bedpan on patient’s voiding/defecation schedule.
Skin Integrity: (3)
List three interventions aimed at treating and preventing integumentary issues while in the acute care setting.
1. Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection.
2. Pay special attention to high-risk areas such as bony prominences, skin folds, sacrum, and heels.
3. Minimize exposure of skin impairment and other areas to moisture from incontinence, perspiration, or wound drainage.
Comfort/Rest/Emotional Care: (3)
List three interventions aimed at providing comfort, rest, and emotional care while in the acute care setting.
1. Assess client’s level of comfort on a consistent basis.
2. Provide a judgment free environment, with acceptance and support.
3. Arrange situations that encourage autonomy.