Patient Initials: E.S Date of Care: 10/15/2018

Assessment & Nursing DX

PATIENT EXPECTED OUTCOME

NSG GOAL & INTERVENTION

SCIENTIFIC RATIONALE

EVALUATION

             30%

                     20%

                  30%

               10%

           10%

Subjective Data:

• Patient said” I hate being stationary”.
• When asked about her response to life style changes, patient claimed “I can never stand up because I know I’m going to fall, and my husband will say why you did that’
• When patient saw me she stated, “I always stay in bed or wheel chair because I cannot walk”

SHORT TERM:

Be free of immobility complications including, skin injuries, fall risks and normal bowel patterns during the shift.

NSG. GOAL

Patient will be able to increase mobility in lower limbs.

Goal was met patient was free of immobility complications during the shift.

Objective Data:

• T: 98.5, P:85, RR: 15, B/P: 119/78, O2 state: 94
• Neuro: alert and oriented, no sensation in lower body.
• Cardiac: 85, regular
• Respiratory: 15 unlabored, lung sounds clear bilaterally.
• GI: good appetite ate 95% of breakfast
• Bowl sounds: active
• GU: incontinent
• Skin: intact, warm, dry and pale
• Musculoskeletal: weakness in right arm and lower limbs.
• pain: no pain.

INTERVENTIONS

Diagnostic: Assess the client for cause of impaired mobility. Determine whether the cause is physical, psychological or motivational  

Evidence base nursing because fear of falling is associated with immobility and functional dependence, it requires effective assessment and measurement. (Ackley,Ladwig,2013, p.538)

NANDA NSG. DX:

Impaired physical mobility related to neuromuscular impairment as evidenced by limited range of motion.

LONG TERM:

Increased range of motion of the lower limbs after 2 weeks

THERAPEUTIC:

Perform passive range of motion at least twice a day unless contraindicated, repeat each movement maneuver three times.

Evidence based: Physical rehabilitation intervention were found to be safe, reduced disability and resulted in few adverse events. (Ackley,Ladwig,2013, p.538)

I’m not there to evaluate the outcomes.

TEACHING:

Work with the client using self-efficacy interventions using single or multiple methods. Teach client and family members to assess fear of falling and develop stragies to mitigate its effect on mobility progression.

Evidence based nursing: Use of self-efficacy-based interventions resulted in increased exercise (Ackley,Ladwig,2013, p.542)

REFERRAL: refer the client to physical therapy for resistance exercise training as able, involving all major muscle groups (e.g. abdominal crunch, leg press, leg extension, leg curl, and calf press)

Evidence based: A Cochrane review found that progressive resistance- strength training for physical disability in older client resulted in increased strength and positive improvements in some limitations. (Ackley,Ladwig,2013, p.540)