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Careplan

NURSING DIAGNOSES EXPECTED PATIENT ASSESSMENT ACTION TEACHING


OUTCOMES interventions: interventions: interventions:

Impaired Memory r/t Pt will strengthen recent -Assess for any signs -Nurse will encourage -Teach pt to eat a
neurological impairment memory capacity by playing that pt may be pt to perform the healthy diet with
(dementia) AEB pt frequently a memory game like Go depressed. memory games twice a adequate intake of
forgetting to void, pts delayed Fish twice a day while day for 7 days to whole grains, fruits,
ability to recall recent factual awake for 7 days ending on -Evaluate all the ensure pt is attempting and vegetables to
information like my name, and 10/25/2017. medications pt is to improve short-term decrease
pt history of dementia. taking in order to memory. cerebrovascular
determine if one could deficits.
have adverse effect of -Encourage pt to use
impairing memory. cues, alarms, -Teach pt to use
calendars, and lists to memory techniques
-Perform a nutritional promote memory and such as concentrating
assessment to ensure trigger actions at and attending,
pt does not need designated times. repeating information,
supplementation with making mental
foods/vitamins because associations, and
may contribute to placing items in
cognitive deficits. strategic places so they
will not be forgotten.
Impaired physical mobility R/T Pt will build up muscle -Do complete pain -Nurse will administer -Encourage pt to
alteration in cognitive strength to be able to assessment every shift. pain medications PRN. verbalize any pain felt
functioning (dementia); body transfer independently by with movement
mass index >75th percentile for standing on both feet while -Monitor pts ability to -Nurse will monitor especially during
age (morbid obesity); reluctance holding onto Rolling Walker tolerate activity and the pt while he stands transfers.
to initiate movement AEB use of for a minimum of 2 minutes use all 4 extremities for 2 minutes three
WC and RW; history of morbid noting pulse, skin times a day to ensure -Teach pt to do deep
three times a day at 0730,
obesity color, and B/P before pt performs task. breathing exercises to
1100, and 2030 for 5 days
and after transfers and Nurse will execute help with lung
ending on 10/23/2017. PT sessions. passive and active expansion and use an
ROM exercises on pts incentive spirometer to
legs to avoid muscle promote better
fatigue and cramping.
breathing when
exercising.
-Nurse will watch for
orthostatic -Teach pt to stand up
hypotension while pt is slowly by dangling feet
moving and
from side of bed,
transferring.
flexing and extending
legs several times after
sitting up, and standing
up slowly using the RW
for support to avoid
lightheadedness and
dizziness.
References
Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based guide to
planning care (11th ed.). St. Louis, MO: Elsevier.
Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and
management of clinical problems(10th ed.). St. Louis, MO: Elsevier, Inc.