#1 Nursing dx: Lack of understanding related to language barrier as evidenced by primary language

being Marshallese and giving inconsistent answers.

Expected outcome: Communication is effective between patient and staff throughout the day.
Nursing Interventions
Patient Responses to interventions
Patient denied the use of an interpreter and said his
1. Assess which language the patient prefers
main and primary language is Marshallese but English
and if interpreter is needed.
is ok.
I know my patient doesnt understand half of what is
being said to him because most of his answers are
answered with yes even if its an open question. But
2. Use alternative methods to get the message
when rephrased or use hand motions the patient then
across to the patient such as rephrasing, pen
nods in understanding and answers the question
and paper, or hand motions
appropriately. Using hand motions also worked. For
example when I asked if he brushed his teeth already
he answered no but when I motioned brushing my
teeth he said, oh yes I brushed my teeth.
Patient cooperated and rephrased the requested asked
3. Ensure that the patient understands by asking
to demonstrate that he understood what was being
the patient to rephrase in their own words
talked about.
Evaluation of whether outcome(s) are met: I feel like communication between me and my patient was
effective. The patient seemed happier once when he started to understand what was happening around
him. I helped clarify what he wasnt sure about and I helped the Pre-Op nurse with information that the
patient did not inform the nurse because he didnt understand her questions. The patient understood a lot
more when the son and cousin interpreted while they were in the room. I suggest that the patient get an
interpreter to understand and make important decisions, if not a family member should stay to help
interpret when possible.

#2 Nursing dx: Risk for falls related to post surgery of amputation of the 2nd toe

Expected Outcome: Patient will not fall during shift

Nursing Interventions
Patient Responses to interventions
Patient has no history of falls. Patient reports of cataracts but says he
1. Assess factors that increase
can see. He uses a front-wheeled walker to ambulate and uses it
the level risk for falls.
properly. He takes antihypertensive medication with possible side
effects of dizziness and hypotension. Patient is very independent.
Patient is connected to the IV so the tubing can trip the patient if it's
2. Assess the environment for
too long and hanging all over the place. The computer monitor opens
factors to known to increase
up and blocks the walkway. His BP cuff tubes are long and can be in the
falls.
patients walkway as well if laid out. I made sure that the patient could
ambulate around the room freely.
Patient wears the non-skid socks when in room and when ambulating
3. Encourage patient to wear
around the hospital he puts on his shoes. I suggest that he get a fitted
appropriate clothing and foot
shoe that doesnt cause further trauma to his amputation site with
wear.
continuous rubbing. Patient said he is going to get another shoe when
he gets discharged.
Patient has he call light, front-wheeled walker, urinal, bedside
4. Place items used by the
commode, and personal phone within reach. He understands that if he
patient within easy reach.
keeps these things in reach it will be easier on him and decrease the
risk for falls.
5. Ensure appropriate room
Patient tends to not turn on the lights. I turned on the lights and he said
lighting
that is a lot easier to see.
6. Educate the patient about risk
Patient confirms that he knows and understands what to do by
factors for falls and what to do
repeating what to do back to me.
when a fall occurs.
Evaluation of whether outcome(s) are met: Outcome was met and patient was educated to keep room and
environment organized, use the lights to help with vision, and keep things close by or in reach. Patient
does a pretty good job with keeping his room organized because he told me where and how thing belongs.
Patient understands what increases his risk of falling but he still needs monitoring to ensure his safety.