Nursing Care Plan Assessment equals Data Collection + Analysis| Nursing Diagnosis – Actual/Potential| Nursing Goal(SMART)| Nursing Interventions/ActionsInclude Rationale/Reference| Evaluation| Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker, Hypertension, Fall at home, Bradycardia, Hyperlipidemia. Neurological: Alert, Oriented x 4. Diet as ToleratedActivity as tolerated. Does not want to do physiotherapy.
Would prefer to remain in bed. Will only move her arms and legs and adjust as needed. | Activity Intolerance related to weakness, bed rest and immobility as evidenced by client verbalizing lack of interest/desire in activity. Risk for falls related to generalised weakness and impaired mobility as evidenced by client having a history of fall in the past. Hopelessness related to failing or deteriorating physical condition as evidenced by client stating “Why god is not calling me to him”. | 1. Client will participate in daily activity with vital signs within limit in a week’s time. 2.
Client will perform ADLs with some assistance, e. g. , toilets with help ambulating to bathroom, by discharge. 1. Client will not experience a fall by identifying risks that increase susceptibility to falls by the end of the day. 2. Client and caregiver will apply tactics and ways to increase safety and provide a safe home environment. 1. Client will initiate behaviours that may reduce feeling of hopelessness by the end of week. 2. Client will be hopeful verbalizing optimistic plans after she is discharged and reaches home. | 1. Record client’s vitals before and after any activity.
Rationale: Variation can be caused by temporary insufficiency of blood supply (Ackley & Ladwig, 2008, p 119). 2. Administer pain medications prior to activity. Rationale: Pain restricts client from performing maximum activity and may worsen the movement (Ackley & Ladwig, 2008, p 120). 3. Encourage client to change position gradually, dangle, sit, stand and ambulate as tolerated. Rationale: Performing activities slowly at client’s pace and for shorter periods minimizes fatigue (Kozier, 2010, pg. 1126). 4. Teach the client systematic performance of active ROM exercises to maintain and improve joint mobility.
Rationale: These activity increases muscular strength and active movement (Kozier, 2010, pg. 1147). 5. Encourage client plan activities with alternate periods or rest and activity. Rationale: Assistance in planning daily routines that maintain a balance between activity and rest may be necessary to conserve energy (Day, 2010, pg. 1744). 6. Reinforce importance of progressive exercise, emphasizing that joints are to be exercised to the point of pain and not after that. Rationale: Pain occurs as a result of joint or muscle injury.
Continued stress on joints or muscles may lead to more serious damage and limit ability to move (Gulanick &Myers, 2010, pg 136). 1. Place objects used by the client within her reach. Rationale: Client can lose balance and might fall when she is trying to get items that are out of reach (Kozier, pg 775, 2010). 2. Emphasize and educate client about the importance of nutrition especially vitamin D supplementation in relation to reducing fall risk. Rationale: Proper diet along with Vitamin D supplement raises calcium which reduces falls and falls related fractures (Best Practice Guidelines, 2005, Rec. 05). 3. Consult with other health care team members such as OT/PT to help resolve mobility issues. Rationale: Interprofessional collaboration results in a sharing of expertise to enhance the quality of patient care (Kozier, pg 776, 2010). 4. Encourage client to do exercises and activity as tolerated to maintain muscle strength and joint flexibility. Rationale: A routine of exercises such as Tai chi can enhance balance and improve overall muscle strength (Best Practice Guideline, Rec. 2. 1, 2005). 5. Educate client to stay in the lower level of house such as bedroom/washroom or everything in one floor.
Rationale: Having all daily required amenities nearby will reduce client’s risk of falling. (Kozier, pg 774, 2010). 6. Increase client’s awareness by highlighting the risk factors associated with falls within home; removing unsafe objects. Rationale: Risk factors such as clutter, unsecure rugs, extra loose tripping clothing and inadequate lighting hampers the motivation for mobility (Kozier, pg 774, 2010). 1. Creating a therapeutic nurse-client relationship by listening attentively and increasing her positivity by talking about her past pleasant experiences.
Rationale: Encourage client to share feeling and reflecting on past accomplishments, positive memories and significant milestones (Day, 2010, pg. 434). 2. Encourage client to become involved in activities on the unit like interacting with staff, other clients, participating in therapy and recreational activities. Rationale: This will help distract her mind from a preoccupation with her illness (White, 2005, pg. 1326). 3. Provide things to do when client is feeling down, like, crossword puzzle, reading books, watching TV.
Rationale: This provides time to shift her attention to more creative activities, and will see the situation not so utterly and hopeless (White, 2005, pg. 1326). 4. Teach client to substitute negative self-talk with positive self-talk. Rationale: Focusing on individual’s strengths and abilities enables and support hope (Day, 2010, pg. 434). 5. Encourage client to spend increased time with family and loved ones. Rationale: Clients who live alone with no family support are more prone to hopelessness (Carpenito-Moyet, 2008, pg. 329). 6.
Encourage client to engage in creative activities to tap their resources. For example, music, art, storytelling, quilting etc. Rationale: Expressive arts are framework for identifying personal strengths (Kozier, 2010, pg. 1440). | 1. Client performs activities within daily limits of vital signs. 2. Based on the pain scale verbalized by client, pain medication is administered 30 minutes prior to the start of daily activity. 3. Client demonstrates changing of positions within her tolerance limits. 4. Client understands and demonstrates ROM exercises to improve her mobility. 5.
Client discussed importance of activity and rest patterns to manage energy and prevent fatigue. 6. Client understands importance of exercise and looks forward to physiotherapist appointment and also does regular exercise at home as tolerated. 1. Nurse makes sure that client has all the necessary things in within reach before leaving the room. 2. Client understands importance of nutrition in reducing risk for fall and eats appropriately. 3. Client looks forward to Occupation/Physical Therapy appointments. 4. Client understands importance of exercise and also does regular exercise at home as tolerated. . Client verbalized a plan to make changes at home to ensure safety. 6. Client is aware of potential risk for falls and keeps home clutter free and safe. 1. Client seems positive about her life talking to health care team. 2. Client socializes with other people on the floor and looks forward to any recreational activity. 3. Client sets target to finish some part of her magazines and puzzles book before a certain time of day like before breakfast or lunch comes. 4. Client understands and verbalizes the improvement in her health rather than her initial diagnosis. 5.
Client makes plans to meet with family and friends every one or two week as per everyone convenience. 6. Client keeps herself occupied either by reading books, watching TV, listening to music or knitting etc. | References (Day,R. A. , Paul, P. ,Willaims, B. , Smeltzer, S. C. , Bare, B. (2010). Textbook of Canadian Medical-Surgical Nursing (pp. 982-983). Williams & Wilkins. White, L. (2005). Foundations of nursing. Australia United States Clifton Park, NY: Delmar Learning. Carpenito-Moyet, L. J. (2008). Nursing care plans & documentation, nursing diagnoses and collaborative problems. 5 ed. ). Philadelphia, PA: Lippincott Williams & Wilkins. Ackley, B. J. , & Ladwig, G. B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed. ). St. Louis: Mosby Elsevier. Kozier, B. , Erb, G. , Berman, A. , Synder, S. , Bouchal, S. R. , & Hirst, S. (2010). Fundamentals of canadian nursing, concepts, process and practice. (2 ed. ). Toronto: Pearson Canada. Gulanick, M. , & Myers, J. L. (2010). Nursing care plans, diagnoses, interventions, and outcomes. (7 ed. ). PA: Mosby.
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