A Nursing Care Plan and Medication
(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)
(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.)
Save your time - order a paper!
Get your paper written from scratch within the tight deadline. Our service is a reliable solution to all your troubles. Place an order on any task and we will take care of it. You won’t have to worry about the quality and deadlinesOrder Paper Now
(List at least two nursing or collaborative interventions with rationale for each goal & outcome.)
(Provide reason why intervention is indicated/therapeutic; provide references.) A Nursing Care Plan and Medication
Outcome Evaluation & Replanning
(Was goal(s) met? How would you revise the plan of care according the patient’s response to current plan of care?)
1. +2 weakness on left
upper and lower
2. Inability to walk without
shuffles when walks and
gets confused as to
which leg needs to
move to propel forward)
Statement #1: Patient will perform ROM exercises each hour during the shift.
Statement #2: Patient will ambulate from bed to door twice by the end of shift.
1. Educate pt about importance of ROM exercises. Rationale: If pt understands the importance of ROM exercises (to maintain and hopefully increase strength), the pt is more likely to participate in exercises (Potter & Perry, p. 4).
2. Assist pt w/ ROM exercises while teaching him how to perform ROM exercises.
3. Consult with physical therapist for strength training and development of a mobility plan
1. Determine amount of assistance needed to get patient out of bed and ambulate. A Nursing Care Plan and Medication
2. Clear walkway of hazards. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3).
1. If patient understands the important of ROM exercises (to maintain and hopefully increase strength), the patient is more likely to participate in exercises (Potter & Perry, p. 4).
2. Pt needs to be instructed on how to perform ROM exercises, and performing the exercises while instructing the patient will solidify his understanding so he can perform exercises on his own (Potter & Perry, p. 5).
3. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitation patients (Tempin, Tempkin, & Goodman, 1997)
1. Weakness and lack of coordination can cause the pt to be off balance which would put him at risk for a fall. Determining level if assistance needed before trying to assist out of bed and ambulate will prevent a fall for the patient (Potter & Perry, p. 2).
2. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3).
Outcome #1: Pt partially met goals. He was open to and understanding of the need to perform ROM exercises, but he still needs guidance in how to perform. Will continue to with current plan.
Outcome #2: Patient exceeded goal: he walked 4 times. Wil modify plan to increase distance (to nurses’ station). A Nursing Care Plan and Medication