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) site. 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 ambulation) 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. process) References: Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: a guide to planning care. St. Louis: Mosby, Inc.
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