Question

A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) a. Conducting a home-safety assessment and identifying hazards in the patient's living environment b. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury c. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching d. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye e. Alerting other nurses and health care providers about patient's visual status during hand-off reports

Short answer

The priority nursing interventions during patient admission are c, d, and e, as they address immediate safety, orientation, and communication about the patient's condition to ensure proper care.

Step-by-step solution

Understanding the Patient's Condition

Recognize the patient is recovering from severe bilateral eye trauma, which likely impairs vision and may increase the risk of falls or further injury. A nurse's priority is to ensure safety and prevent further harm.

Identifying Priority Interventions

Assess the interventions listed, keeping in mind that immediate safety and support for the patient during the hospital stay are the priorities. Consider which actions will directly prevent further injury or harm in the short term.

Selecting Appropriate Interventions

Choose the interventions that are most relevant to the patient's immediate needs after the trauma and during hospital admission, which are: - Placing necessary objects within easy reach to prevent falls (c).- Orienting the patient to the environment to reduce anxiety and prevent incidents (d).- Communicating the patient's visual status to other healthcare providers for continuity of care (e).

Evaluate Remaining Options

Review the remaining options (a and b) to determine if they are relevant to the nurse's immediate priorities during hospital admission. These actions are essential but are more relevant for preparing the patient for discharge or long-term care.

Key concepts

Patient Safety

Ensuring patient safety is paramount in nursing, especially for individuals who have recently experienced severe trauma, such as bilateral eye trauma. Patient safety entails creating an environment that minimizes the risk of additional harm to the patient during their hospital stay.

For a patient with impaired vision due to eye trauma, simple yet crucial actions can significantly reduce the risk of falls and further injury.

• Placing essential items like the nurse call button and water within easy reach prevents the patient from making hazardous movements that could lead to accidents.
• Orienting the patient to their surroundings helps them navigate the space safely, thereby reducing anxiety and the chances of injury.
• Communication is also a key component of patient safety, and it's important to alert all healthcare providers involved in the patient's care about their current visual status. This ensures continuity of care and appropriate handling of the patient, mitigating the risk of miscommunication that could compromise safety.

In summary, interventions are chosen judiciously to support immediate safety needs, with a focus on minimizing risk in the patient's current environment and ensuring professional caregiving is adequately informed.

Eye Trauma Care

Care for a patient with eye trauma goes beyond the initial treatment; it requires comprehensive management to prevent secondary complications and support recovery.

Essential interventions for eye trauma care include:

• Assessing the patient's environment for hazards that could worsen their condition.
• Ensuring the patient's immediate surroundings are safe and objects are placed within easy reach, as traversing unfamiliar or cluttered spaces can lead to accidents that may exacerbate eye injuries.

Although assessing the home environment and advising on eye safety in personal activities are critical, they are generally part of long-term care planning and are not immediate priorities during the acute phase of hospitalization.

Proactively Managing Potential Complications

Proper eye trauma care involves routinely checking for signs of infection, managing pain, and regularly updating the care plan based on the patient's healing progress. Education on eye safety is also a core part of eye trauma care but is more relevant post-discharge, helping to prevent future incidents.

Nurse-Patient Communication

Effective nurse-patient communication is essential in delivering high-quality healthcare and ensuring patient safety. In the context of a patient with severe bilateral eye trauma, communication takes on added significance due to the patient's potential anxiety and the need for a clear understanding of the care environment and routines.

Communication strategies include:

• Using verbal cues to orient the patient to their surroundings.
• Clearly explaining the placement of essential items to aid the patient in moving around safely.
• Ensuring that all healthcare providers are aware of and understand the patient's visual limitations, so appropriate adjustments to care can be made.

Building Trust through Compassionate Interaction

Expressing empathy, actively listening to the patient's concerns, and providing reassurance can build a trusting relationship, which is crucial for a positive recovery experience. Finally, communicating effectively with other health professionals during shift changes and hand-offs is essential to maintain a high standard of care and patient safety.