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Care Plan- Impaired Physical Mobility

Course: Adult Nursing 3 (2207)

45 Documents
Students shared 45 documents in this course
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BAPTIST HEALTH COLLEGE LITTLE ROCK - SCHOOL OF NURSING
NURSING CARE PLAN
Student: Savanna Woodham Instructor: Dr. Kaucher
Week #:_14____________ Day: 1
Medical Diagnosis: Acute Respiratory failure with hypoxia
ASSESSMENT PLAN IMPLEMENTATION/EVALUATION
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.
Goal Statement (Expected 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
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.
Goal Evaluation (Actual Outcome)
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).
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.
Maslow’s Need: Psychological Needs
SOURCE (in APA format): Gulanick, M., & Myers, J.L. (2015). Nursing Care Plans: Diagnoses, interventions, and outcomes (9th ed.) Elsevier Health Science