In the current scenario, Mr. Smith, a geriatric patient, recently encountered an accident that impacted his left cerebrovascular. The accident resulted in reduced visual field as well as residual weaknesses in his right leg and arm, which has consequently affected his mobility. Currently, Mr. Smith uses a walking stick to aid in his movement. He is under metoprolol to regulate his blood pressure. He also started using Coumadin after the physician found that he had atrial fibrillation. Given his condition, the nurse and the patient should take appropriate measures to prevent falls during his ambulation, such as always using a walker. The nursing interventions and rationale for taking such measures are detailed in the table below:
| Intervention | Rationale |
| The nurse should ensure that Mr. Smith’s room is safe in all ways. That is, they should ensure that the bed is in a down position and that the bed rails are up (Bauman et al., 2014). Also, to minimize Mr. Smith’s movement, they should ensure that he can access all essential items in the room. Additionally, the nurse should remove any blockades in the room, including any unfit carpets or fallen materials that may facilitate his falling in case he walks round in the room (Cameron et al., 2018). The patient should have anti-skid socks. Also, the nurse should advice Mr. Smith to always use his walking stick when moving around the room. | The rationale behind ensuring that the bed rails are up is to prevent any falls from the bed when Mr. Smith is sleeping. Having the bed in a down position ensures that the patient is comfortable and minimizes the chances of moving out of the bed. Accessibility to appropriate essential materials in the room prevents Mr. Smith from having to walk around the hospital in search for some of these essential items (Cameron et al., 2018). Besides, ensuring that the room has no blockades and that Mr. Smith has anti-skid prevents chances of sliding and falling. Using a walking stick is essential for offering additional support. |
| To take care of Mr. Smith’s sensory and perception disorder, the nurse should ensure that Mr. Smith has a consistent physical environment based on a daily routine. Additionally, they should ensure to present Mr. Smith with familiar objects in a low-stimulation environment since overstimulation may increase disorientation (Khan & Khan, 2021). The nurse should also ensure that the patient gets enough sleep, rest, and daytime naps. The nurse should also engage the patient with current activities, that is, here and now, activities that focus on concrete and reality-oriented things that are outside the self. | By providing a consistent physical environment, the nurse eliminates the element of overstimulation, confusion, and surprise. Besides, providing familiar objects would prevent confusion (Khan & Khan, 2021). Additionally, ensuring low-stimuli consistency guarantees that the cognitive status is not affected in a negative manner. Avoiding overstimulation prevents sensory block of meaningful stimuli. Besides, ensuring that a patient with sensory and perception disorder has rested and slept enough minimizes chances of overstimulation. Besides, fatigue may contribute to increased condition. Presenting the patient with current activities helps them in differentiating between reality and their own thoughts. |
