SCENARIO 1 16/6/2021 Mrs. Dolly Sookdeo an 85-yr-old woman was admitted to ward 11 medical from the Royalty Geriatric Home at 6.30am with a history from caregiver that patient was found slumped on her...

List 15 nursing interventions with rationale for Risk for Impaired Skin Integrity based on the scenario

Extracted text: SCENARIO 1 16/6/2021 Mrs. Dolly Sookdeo an 85-yr-old woman was admitted to ward 11 medical from the Royalty Geriatric Home at 6.30am with a history from caregiver that patient was found slumped on her chair with saliva drooling from her mouth just after she had eaten breakfast. She came to hospital via an ambulance. Was seen in the A& E department, ECG was done, blood was taken for CBC, electrolytes, LFT, RFT and RBS and an IV access was inserted on Patient's Right wrist. Patient was seen on ward by doctor and diagnosed as Cerebrovascular Accident (Stroke) and Hypertension. Plan of care included 1. Start Intravenous infusion 2L/24 hours Ringers lactate alternate with 5% Dextrose Water (2) Give Aldomet 250mgs tds (3) Monitor blood pressure q4h (4) chase blood reports (5) Give soft diet and oral fluids as tolerated. 17/6/2021. 8am. Patient taken over awake and alert but confused and not oriented to time, place or person. Intravenous infusion 5% D/Saline in progress. Patient unable to feed self and is taking a long time to complete meals. Patient has difficulty speaking, and becomes very irritable and cry while trying to communicate. She is incontinent of urine and feces, has right sided weakness with inability to move right hand or foot, skin dry and mucus membrane (lips) dry and cracked. Relatives claim that prior to CVA patient used a cane to assist in walking but now patient is unable to get out of bed due to right sided weakness. Her blood pressure fluctuated during the night shift at 6.00 am. TPR-37. 100. 20. BP 145/95.