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San Joaquin Valley College

RN 11 Program NURSING CARE PLAN

Student:__RAVNEET KAUR

Client initials:_JR_______

Room#__274______

Date: 8/5/12______

ASSESSMENT

NURSING DIAGNOSIS

GOAL

OUTCOME CRITERIA INTERVENTIONS RATIONALE

EVALUATION

Subjective: 58 year old male diagnosed with infected left hip, epilepsy, hypertension, hyperlipidemia, left side CVA, coronary arteries disease, and BPH. Allergies/Reaction: Aspirin, PCN,Tuna, Bubble bee: swells up and could not breath. No HX of smoking, alcohol consumption, and illegal drugs. Patient stated that he cant move from side to side without experience pain. He also stated that he cant ambulate himself from spine to sitting position in bed without

Impaired bed mobility r/t on going effects of CVA, pain and musculoskeletal impairment a.e.b. screaming upon changing positions in bed due to pain, insufficient muscle strength, and extreme weakness.

Patient will be able to ambulate in bed by himself without experiencing any pain and difficulty by the end of the shift.

Patient will be able to demonstrate techniques and behaviors that will enable safe repositioning by end of the shift.

1.Demonstrate and assist with transfer techniques and use of mobility aids.

1. Facilitates self-care and clients independence. Proper transfer techniques prevent shearing, abrasions, and dermal injuries (Ackley & Ladwig, 2008, p 567).

2.Encourage continuation of exercise.

2. Will help to maintain and enhance gains in strength and muscle control. 3. These clients may become fearful and dependent and although assistance is helpful in preventing frustration. It is important for client to do as much as possible for self to maintain self-esteem and promote recovery.

3.Avoid doing things for client that client can do for self and provide assistant as necessary.

Goal partially met. Patient is able change position from supine to sitting and sitting to supine in bed without experiencing any pain and difficulty. Will continue the care plan because patient is not able to ambulate himself from bed to chair yet.

Reference: Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

San Joaquin Valley College


RN 11 Program NURSING CARE PLAN
assistant and pain. Objective: Paralysis of the left arm screaming of pain, physical weakness, impaired ability to change and control body position, edema and extreme pain in the left foot upon ambulation. Pain level 6/10 without ambulation.

Reference: Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

San Joaquin Valley College


RN 11 Program NURSING CARE PLAN

Reference: Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.