A geriatric patient is unsteady after ambulating from a chair. Which measure should the nurse take all except:
Rationale: Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing: Assessment and management of clinical problems (11th ed.). Elsevier.
The correct answer and explanation is:
The correct answer is: Encourage the patient to continue ambulating without assistance to promote independence.
Explanation:
Unsteadiness after ambulating from a chair is a common issue in geriatric patients due to age-related changes in balance, muscle weakness, or underlying medical conditions such as orthostatic hypotension or neurological impairments. The priority for nurses is to ensure patient safety while promoting mobility.
Appropriate Measures for an Unsteady Geriatric Patient:
- Assess the Cause of Unsteadiness: The nurse should evaluate whether the patient’s unsteadiness is due to dizziness, muscle weakness, or hypotension. Orthostatic hypotension, for example, occurs when blood pressure drops upon standing, leading to dizziness and potential falls.
- Assist the Patient When Standing: Helping the patient rise slowly from a seated position allows the body to adjust to changes in position, reducing the risk of falls. Using assistive devices like walkers or canes can enhance stability.
- Encourage the Use of Supportive Devices: Geriatric patients often benefit from assistive mobility devices such as walkers, grab bars, or handrails. These tools provide additional stability and prevent falls.
- Monitor for Fall Risk Indicators: The nurse should assess the patient’s gait, posture, and overall physical condition. Conducting a fall risk assessment using standardized tools like the Morse Fall Scale can help determine the level of assistance required.
Why Encouraging Unassisted Ambulation is Incorrect:
Encouraging a patient to continue walking without assistance after showing signs of instability increases the risk of falls, which can lead to serious injuries such as hip fractures or head trauma. While independence is important, safety should always be the priority. Instead, supervised ambulation with gradual strength training and balance exercises is recommended.
By implementing appropriate fall prevention strategies, nurses can ensure that geriatric patients maintain mobility while minimizing the risk of injury.
Now, I’ll generate an image to illustrate this scenario.
Here’s the generated image illustrating a nurse assisting an elderly patient who appears unsteady while getting up from a chair. Let me know if you need any modifications or additional details!
