Nursing Care Plan - Download as DOC by feltonhuggins


									                                                                                    Nursing Care Plan
Student Name/Date: Sarah Voelpel (Clinical Week 2)

                                               Expected Outcomes                            Nursing Interventions/Rationale                         Outcome Evaluation
        Nursing Diagnosis                    (Short term (8-48 hr.) reasonable
                                                                                            List all interventions for each nsg. dx (include      (Patient outcome noted as met or
    (Dx, related to, & as evidenced by)     expectations stated in measurable,
                                                                                                         patient/family teaching)                   unmet/responses described)
                                            behavioral terms, i.e., action verbs)

Impaired physical mobility r/t            Client will sit up in bed and                 Increase independence in ADLS,                         Patient met this outcome by the
sever curvature of spine and              hang legs off the side by                     encouraging self-efficacy and                          end of my shift on day two post
recent laminectomy AEB right leg          herself by day two post                       discouraging helplessness as client gets               surgery. She was very eager to
limp when walking, slow and               surgery.                                      stronger. (Some clients may feel only like             eat in a chair next to the bed on
cautious movement, and need for                                                         resting after surgery, however,                        her own, which encourged her to
assistance when changing                                                                encouragement from the nurse can                       get herself up and out of bed.
positions or ambulating.                                                                persuade the client to get moving as soon
                                                                                        as possible so that the client will gain
                                                                                        mobility quickly and be able maintain
                                                                                        ADLS once leaving the hospital)

                                                                                        Screen for bed mobility at least two times
                                                                                        a day. (This will ensure that the client is
Other Nursing Diagnosis                                                                 progressing in ability to move and provide
                                                                                        sufficient time for intervention if mobility
Risk for constipation related to                                                        proves to be decreasing)
narcotic use, decrease in activity
post surgery, and lack of bowel                                                         Instruct client to log roll onto side and
movement within two days post                                                           lower legs slowly off the bed while
surgery.                                                                                pushing up with elbow to sit at the side of
                                                                                        the bed. Avoid twisting movements. (This
Risk for infection related to large                                                     will promote the client’s ability to perform
incision on back and constantly                                                         tasks independently and provide a basic
laying on area which may lead to                                                        guideline of movement to decrease the
moisture accumulation around                                                            risk of injury)
                                          Client will ambulate for five                 Before activity, observe for and treat pain,           I expect this outcome to be met
Risk for falls related to age,            minutes using walker at a                     while ensuring that client is not overly               based on the fact that the client
narcotic use, recent surgery, six         moderate pace by day three                    sedated. (Getting pain under cotrol will               was able to walk to the bathroom
previous hip fractures, and               post surgery.                                 encourage the patient to move and start                with the assistance of the nurse
limited mobility from spinal                                                            gaining mobility; pain can discourage the              by day 2 post surgery and walk
curvature.                                                                              client from getting out of bed)                        with the assistance of her
                                                                                                                                               husband around the unit on that
                                                                                                                                               same day. The patient expresses
Acute pain related to                                                 Perform passive range of motion (PROM)        a strong desire to get up and
osteoarthritis aggravated by                                          on all limbs on day one post surgery and      moving as soon as possible.
movement AEB grimacing when                                           active ROM on all limbs on days 2-4 post      Working up to ambulating alone
after long periods of movement                                        surgery. (Performing PROM exercises can       will give her time to become
and patients statements of                                            keep the client’s limbs mobile and ready      more comfortable with it again.
experience pain during long days                                      for ambulating. It also provides the client
of activity.                                                          a way of gaining motion while still in bed)

                                                                      Aid client in ambulating with nurse using
                                                                      gaitbelt for at least five minutes on days
                                                                      2-3 post surgery. (This will allow the
                                                                      nurse to gauge the client’s progress with
                                                                      ambulation and decrease the risk of
                                                                      falling and injurying themselves during

                                   Client will agree to participate   Provide referrals to several appropriate      I expect this outcome to be met
                                   in physical therapy after          physical therapy clinics near the patient’s   also because the patient has
                                   leaving hospital before being      home. (The patient will be more likely to     experienced the benefits of
                                   discharged (day four post          comply with treatment if the location is      physical therapy after previous
                                   surgery).                          convenient and they do not have to search     surgeries and injuries and she
                                                                      for what clinic they should go to)            has a desire to gain back as
                                                                                                                    much mobility as possible.
                                                                      Offer to help patient schedule an             She is hopeful that she will
                                                                      appointment if she needs help. (This will     return to her state of mobility
                                                                      take the stress of scheduling off of the      previous to her first
                                                                      patient and ensure the nurse that the         laminectomy. As far as ensuring
                                                                      client has made, at least, a tentative        that this outcome is met, the best
                                                                      commitment to go to physical therapy)         that the nurse can do is to offer
                                                                                                                    the client referrals and discuss
                                                                      Discuss and help organize a means of          the benefits of physical therapy
                                                                      transportation to and from physical           after surgery. Also, allow time
                                                                      therapist and support group for continuing    for the patient to ask any
                                                                      her physical therapy while at home. (This     question and arrange a meeting
                                                                      will ensure that the patient can              with the doctor is necessary.
                                                                      realistically incoorporate physical           Still, the client seems very
                                                                      therapy into their daily life and have the    enthusiastic to meet this
                                                                      emotional support to promote the healing      outcome.
References: Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: a guide to planning care. St. Louis: Mosby, Inc.

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