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Student:__RAVNEET KAUR
Client initials:_JR_______
Room#__274______
Date: 8/5/12______
ASSESSMENT
NURSING DIAGNOSIS
GOAL
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 cant move from side to side without experience pain. He also stated that he cant ambulate himself from spine to sitting position in bed without
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.
1. Facilitates self-care and clients 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.
3.Avoid doing things for client that client can do for self and provide assistant as necessary.
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.
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.
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.