|
Assessment
|
Nursing DX/Clinical Problem
|
Client Goals/Desired Outcomes/Objectives
|
Nursing Interventions/Actions/Orders and
Rationale
|
*I
|
Evaluation
|
|
Subjective
Pt’s daughter states that her mother was experiencing progressive right sided weakness
over 2 days prior to admission.
Objective
Diagnosis of stroke
Pt demonstrates right sided paralysis
Pt demonstrates decreased grips and reflexes
on the left side
Pt demonstrates difficulty with mobility and
activity.
|
Problem:
Impaired Physical Mobility
|
Long Term:
Pt will be able to ambulate around the nurses’ station 2X by discharge.
|
* Apply any ordered brace before mobilizing
the client.
Rationale:
“Brace support and stablilize a body part,
allowing increased mobility.” (Ackley & Ladwig, 2008, p 552).
*Increase independence in ADLs
Rationale:
“Providing unnecessary assistance with transfers
and activities may promote dependence and a loss of mobility.” (Ackley & Ladwig,
2008, p 552).
*Obtain any assistive devices needed for activity.
Rationale:
“Assistive devices can help increase mobility.”
(Ackley & Ladwig, 2008, p 552).
|
ü
|
|
|
|
R/T:
Musculoskeletal impairment secondary to stroke
|
Short Term:
Pt will perform passive range of motion exercises by the end of this shift, by 1900.
|
*Assess the pt’s pain by using the 10 point pain rating scale q4 hrs or PRN.
Rationale:
“Single- item ratings of pain intensity are valid and reliable as measures of pain
intensity.”
“The client’s report of pain is the single most reliable indicator of pain.”
(Ackley & Ladwig, 2008, p. 604-605).
*Before activity, treat pain.
Rationale:
“Pain limits mobility and is often exacerbated by movement.” (Ackley & Ladwig,
2008, p 552).
|
|
|
|