Assessment
Related Content Underlying Principles Nursing Interventions
Infiltrations is when IV Findings include: Treatment:
solution or medication - Pallor - STOP the infusion and
leaks into the - Local swelling at the site remove the catheter
subcutaneous tissue. - Decreased skin - ELEVATE the extremity
Infiltration is the leak of a temperaure around the site - Encourage AROM
non-vesicant (fluid that - Damp dressing - Apply warm or cold
doesn't irritate tissue). - Slowed rate of infusion compress depending on
the solution infusing.
- Restart the infusion
PROXIMAL to the site or in
another extremity.
Prevention:
- Carefully select the site
and catheter.
- Secure the catheter.
, Description of Skill
The use of a cane is given to increase stability and support indviduals that suffer from muscle
weakness, while also reducing load of total body weight.
Nursing Interventions (pre, intra, post)
Pre: asses the pt’s ROM, strength, &
mobility. Educate pt on the correct use of a
Indications cane.
- Maintain or regain body alignment and Intra: show proper positioning and cane
stability. usage such as standing, sitting, waiting,
- Decrease skin and musculoskeletal system have pt demonstrate back to you
changes Post: asses the pt’s ability to ambulate
- Achieve full or optimal ROM
- Prevent contractures
Outcomes/Evaluation
Client Education
-Improved and increased independence with
certain tasks - Maintain 2 points of support on the ground,
- reduced risk of falling keep the cane on the stronger side of the
- strengthening the weaker side from being body, support body weight on both legs.
independent - Move the cane forward 6 - 10 in.
- Next, move the weaker leg forward toward
the cane.
- Finally, advance the stronger leg past
Potential Complications Nursing Interventions
-Poor demonstration or education given to -Assist when needed and monitor patients
the patient can cause complications with the ability to ambulate when they are getting up.
correct use of the cane. sitting down.
- Patient may also begin to fatigue - Offer other devices that can help.
- Mention to the patient that additional
interventions such as, physical therapy and
or at-home assisstance from family
members.