Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

When asked about ambulation, patient reported that he had been walking a few times a day but that his legs felt weak after “a few minutes of walking.”

Objective:

Two medications that the patient receives (Lotensin and Bumex) have muscle weakness and/or muscle pain as adverse effects.

Problem

Impaired walking 

Long Term:

Patient will be able to ambulate around home with no report of weakness by [date].

Nursing student will make referrals for home health aide services for assistance with ADLs. Walking impairment may serve as a barrier to self-care, including eating and drinking.

I

Patient was to be D/Ced to his home 02/05/08 with a home health service of his choice.  Goal is on track to be met.

Nursing student encouraged patient to perform ROM exercises each day in addition to exercises shown by home health providers.

R/T

insufficient muscle strength

Short Term:

Patient will ambulate 3 times, with assistance, to the end of the hallway and back to his room on [date]. 

Nursing student will collect baseline pulse rate/rhythm before walking clients, and reassess after 5 minutes of walking. If either are abnormal, have the client sit for 5 minutes then retake pulse rate. If it is still abnormal, walk clients more slowly and with more help, or for a shorter time. Pulse rate indicates cardiac tolerance; if it rises too high after a few walking trials, the physician should be notified.

Patient reported that he had been ambulating a few times a day. Patient was to be sent home on 02/05/08 so he would probably not have time to ambulate the hallways 3 times before D/C. Goal not met.

Intervention not performed by nursing student.

AEB

patient report of legs “feeling weak” upon ambulation.