weight-bearing status
BMAT adds features to address weight-bearing status and provide significant guidance based on mobility level for patients with “strict bed rest” and those who have various restrictions for “bilateral weight-bearing” (Nelson, 2011). The BMAT will be crucial in assessing Jean’s mobility, mainly because it includes all input from bedside nurses, occupational therapists, physical therapists, and risk management at any multi-hospital health system (Nelson, 2011). Since the tool was developed, it has been recommended by many scholars. However, some scholars suggest that its approach be applied in conjunction with other mobility assessment tools, mainly to ensure accuracy, validity, feasibility and appropriateness of the assessment (Morton, Davidson & Keating, 2011).
The nurse will test the patient’s strength and stability using weight-bearing on only one leg and proceed accordingly. Given the fact that assistive device such as a walker, cane, or walking stick is required for Jean to stand, she may be considered to be on Mobility Level 3. Assessment Level 4 will need the nurse to ask Jean to march in place at the bedside and then advance a step and return his feet. The nurse will evaluate whether the patient exhibits stability while performing different tasks or walking and assess for safety and stability awareness. At this level, the patient will fail to display steady gait and excellent balance, especially when marching and stepping backwards and forwards. The patient will not be able to manoeuvre necessary turns for an indoor mobility test, confirming that the patient is Mobility Level 3. Mobility assessment will discover that the patient needs assistance with various ADL such as walking, bathing, toileting, dressing, eating, getting out of bed and onto a chair and personal grooming. Immobility is affecting Jean’s family and carer, where she is gradually becoming withdrawn, although her friends and sisters visit her at her home.
Assessment of Constipation
Some of the vital signs and symptoms of the patient, including constipation, will be assessed to initiate the patient’s baseline observations (Rosdahl & Kowalski, 2008). Assessment starts with an in-depth, thorough physical and history examination. Nurses will use the Bristol Stool Form Chart to assess the sign of constipation. The normality of a patient stool can be evaluated and determined by comparing it to the Bristol Stool Form Scale (BSFS) (Heaton & Donnell, 2014). It is a 7-point scale applied mostly in research and clinical practices for stool assessment. In most cases, consistency of patient’s stool is a critical element in describing and determining altered and healthy bowel habit (Lacy et al., 2016). Slow intestinal transit leads to broad absorption of water and hard stool, while rapid and swift intestinal transit restricts the gastrointestinal intake of water, thus causing liquid or loose stools (Heaton & Donnell, 2014).
Bowel movement assessment for patient with Class III HF is also crucial, mainly because of patients such as Jean, are immobilized for their conditions may be prone to constipation, due to reduced peristalsis. However, Jean’s constipation symptom can be a consequence of both immobilities as well as malnutrition, such as failure to drink enough water. Lack of mobility and patient’s sedentary lifestyle also put him at high risks of pressure ulcer. Bowel movement assessment for patient with Class III HF is also crucial, mainly because of patients such as Jean who are immobilized for their conditions may be prone to constipation, due to reduced peristalsis. Lack of mobility and patient’s sedentary lifestyle also put him at high risks of pressure ulcer. The nurse will use the Waterlow risk assessment to determine areas at risk of pressure ulcers. The evaluation will also be performed to find out how the nurse can reduce the severity of complications caused by pressure ulcers (Nicol et al., 2004).