University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2022
Views:

126

Pages:

1
Author:

Kristopher Elliott

SCHOOL OF NURSING NURSING CARE PLAN Student: Week #:_14____________ Day: Instructor: . 1 ASSESSMENT Subjective/Objective Data Subjective: Screaming when attempting to perform ROM activity. Stating “It hurts it to bad to move my leg right now.” Patient telling Physical Therapy “I am not doing it today.” Objective: Contracture noted to R stump. Stage II sacral wound Unable to ambulate Pain level 8 out of 10. V/S: BP: 138/90, HR 104, RR 22, SPO2 95% RA. NORCO 10-325mg PRN Facial grimace with movement Nursing Diagnosis {Problem Statement in NANDA format} Impaired physical mobility r/t loss of a limb AEB impaired coordination; decreased muscle strength, control, and mass. Medical Diagnosis: Acute Respiratory failure with hypoxia PLAN IMPLEMENTATION/EVALUATION Goal Statement (Expected Outcome) Goal Evaluation (Actual Outcome) Patient will remain free from complications of immobility, as evidenced by absence of thrombophlebitis, normal bowel pattern, and clear breath sounds by the end of the shift. Planned Intervention/Rationale Goal Met. Patient has clear bilateral breathe sounds, BLE free of redness, calf pain, or localized swelling. Patient with regular bowel pattern, LBM (10/7). 1.Turn and position the patient every 2 hours or as needed. Rationale: Position changes optimize circulation to all tissues and relieve pressure. 2. Give medications as appropriate. Rationale: Antispasmodic medications may reduce muscle spasms or spasticity that interferes with mobility; analgesics may reduce pain that impedes movement. 3. Let the patient accomplish tasks at his or her own pace. Do not hurry the patient. Encourage independent activity as able and safe. Rationale: Healthcare providers and significant others are often in a hurry and do more for patients than needed. Thereby slowing the patient’s recovery and reducing his or her confidence. 4. Execute passive or active assistive ROM exercises to all extremities. Rationale: Exercise enhances increased venous return, prevents stiffness, and maintains muscle strength and stamina. It also avoids contracture deformation, which can build up quickly and could hinder prosthesis usage. Summary Statement of Interventions 1.Patient is assisted with turning every 2 hours by staff. 2.Baclofen 10mg TID is given tor reduce muscle spasms and NORCO 10-325mg is given PRN every 6 hours for pain. Also, 12mcg/hr Fentanyl patch is on the patients at all times. 3.Patient able to feed and provide hydration to themselves with assistance as needed at own pace. 4.Passive ROM was not provided to patient due to patient being in severe pain and not wanting to be touched. Revision of Plan Continue with plan of care.