A female elder has left-sided paralysis from a thrombus formation in the cerebral vascu-lature. Rank the nursing goals of the elder's plan of care in order of importance, starting with the most important goal
a. Instruct her to call for help before moving.
b. Maintain her blood pressure below 120/80.
c. Reinforce occupational therapy for feeding.
d. Use range of motion to prevent contractures.
b, a, d, c
a. The second priority goal for the nurse is to maintain elder safety by instructing her to call for help when moving; this will help to prevent accidents and injury.
b. Using Maslow's Hierarchy of Needs, the most important goal for this elder is to control blood pressure, because hypertension and other factors contributed to the thrombus devel-opment. Thus, to prevent further intimal damage to cerebral and other vessels, the nurse maintains the blood pressure at or below the limit as determined by the health care provid-er.
c. The last goal is using joint flexibility and muscle strength to learn self-feeding. The order of these goals is correct because each goal is dependent on the preceding goal for its suc-cess.
d. The next goal in importance, after B and A, is the prevention of contractures because joint flexibility is easier to maintain than to restore. Also, joint flexibility is important for adap-tation to her physical limitations as she learns to perform activities of daily living.
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