cp impaired bed mobility rl to pain & weakness

San Joaquin Valley College RN 11 Program NURSING CARE PLAN Student:__RAVNEET KAUR Client initials:_JR_______ Room#__274______ Date: 8/5/12______ ASSESSMENT NURSING DIAGNOSIS GOAL OUTCOME CRITERIA INTERVENTIONS RATIONALE EVALUATION Subjective: 58 year old male diagnosed with infected left hip, epilepsy, hypertension, hyperlipidemia, left side CVA, coronary arteries disease, and BPH. Allergies/Reaction: Aspirin, PCN,Tuna, Bubble bee: swells up and could not breath. No HX of smoking, alcohol consumption, and illegal drugs. Patient stated that he can’t move from side Impaired bed mobility r/t on going effects of CVA, pain and musculoskeletal impairment a.e.b. screaming upon changing positions in bed due to pain, insufficient muscle strength, and extreme weakness. Patient will be able to ambulate in bed by himself without experiencing any pain and difficulty by the end of the shift. Patient will be able to demonstrate techniques and behaviors that will enable safe repositioning by end of the shift. 1.Demonstrate and assist with transfer techniques and use of mobility aids. 2.Encourage continuation of exercise. 3.Avoid doing things for client that client can do for self and provide assistant as necessary. 1. Facilitates self-care and client’s independence. Proper transfer techniques prevent shearing, abrasions, and dermal injuries (Ackley & Ladwig, 2008, p 567). 2. Will help to maintain and enhance gains in strength and muscle control. 3. These clients may become fearful and dependent and although assistance is helpful in preventing frustration. It is important for client to do as much as possible for Goal partially met. Patient is able change position from supine to sitting and sitting to supine in bed without experiencing any pain and difficulty. Will continue the care plan because patient is not able to ambulate himself from bed to chair yet. Reference: Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

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Page 1: CP Impaired Bed Mobility RL to Pain & Weakness

San Joaquin Valley CollegeRN 11 Program

NURSING CARE PLAN

Student:__RAVNEET KAUR Client initials:_JR_______ Room#__274______ Date: 8/5/12______

ASSESSMENT NURSING

DIAGNOSIS

GOAL OUTCOME

CRITERIA INTERVENTIONS RATIONALE EVALUATION

Subjective:

58 year old male diagnosed with infected left hip, epilepsy, hypertension, hyperlipidemia, left side CVA, coronary arteries disease, and BPH.

Allergies/Reaction: Aspirin, PCN,Tuna, Bubble bee: swells up and could not breath.

No HX of smoking, alcohol consumption, and illegal drugs.

Patient stated that he can’t move from side to side without experience pain.

He also stated that he can’t ambulate himself from spine to sitting position in bed without assistant and pain.

Impaired bed mobility r/t on going effects of CVA, pain and musculoskeletal impairment a.e.b. screaming upon changing positions in bed due to pain, insufficient muscle strength, and extreme weakness.

Patient will be able to ambulate in bed by himself without experiencing any pain and difficulty by the end of the shift.

Patient will be able to demonstrate techniques and behaviors that will enable safe repositioning by end of the shift.

1.Demonstrate and assist with transfer techniques and use of mobility aids.

2.Encourage continuation of exercise.

3.Avoid doing things for client that client can do for self and provide assistant as necessary.

1. Facilitates self-care and client’s independence. Proper transfer techniques prevent shearing, abrasions, and dermal injuries (Ackley & Ladwig, 2008, p 567).

2. Will help to maintain and enhance gains in strength and muscle control.

3. These clients may become fearful and dependent and although assistance is helpful in preventing frustration. It is important for client to do as much as possible for self to maintain self-esteem and promote recovery.

Goal partially met. Patient is able change position from supine to sitting and sitting to supine in bed without experiencing any pain and difficulty. Will continue the care plan because patient is not able to ambulate himself from bed to chair yet.

Reference:Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

Page 2: CP Impaired Bed Mobility RL to Pain & Weakness

San Joaquin Valley CollegeRN 11 Program

NURSING CARE PLAN

Objective:

Paralysis of the left arm screaming of pain, physical weakness, impaired ability to change and control body position, edema and extreme pain in the left foot upon ambulation.

Pain level 6/10 without ambulation.

Reference:Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

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