Care Plan Example PDF

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Summary

notes for care planes...

Description

Melbourne, Florida Individual Nursing Care Plan NURSING DIAGNOSIS STATEMENT

GOALS

Nursing Diagnosis Statement #1:

LONG TERM GOAL: Client will be less sedentary and more motivated to participate in daily activities and physical therapy and require less assistance from others and ambulation devices within 6 months as tolerated

Sedentary lifestyle: R/T: Activity intolerance, muscle weakness, bilateral foot drop, lack of interest and motivation. AEB: Need for mechanical assistance with Hoyer Lift, wheelchair assistance for ambulation, difficulty changing position in bed, being overweight. self care challenges, and difficulty with ROM and client stating “I don’t feel like doing much of anything and I don’t want to go to physical therapy anymore”. (Wilkinson, 2014 pp. 622-624) Level of Maslow's Hierarchy: Physiological

1. SHORT TERM GOAL: The client will show improved strength and increased tolerance to activity and performance with ADLs within one month by exercising leg and arm muscles 30 minutes a day 3X a week for the next month.

INTERVENTIONS RATIONALE/S

1-1. Assess clients current level of activity tolerance level and barriers to engaging in the activities. Also assess readiness to adhere to the activity and include the client as to what exercises are acceptable to them.

1-2. Schedule times that are convenient for the client and provide encouragement to participate.

1-3. Schedule rest and relaxation periods. Over time increase the duration of the exercise as tolerated.

1.1 The activity prescribed should meet the therapeutic objectives, be within the person’s physiological capabilities and be sufficiently enjoyable to promote continuance (M Gordon, 1976) 1.2. Scheduling a time encourages client participation and promotes a client’s sense of control. Careful effective planning advocates and ensures delivery of quality care (W. Seaback, 2001). 1.3. Appropriate progression prevents overexerting while attaining short range goals. (Gulanic, Myers)

IMPLEMENTATION

EVALUATION

(Write nursing progress note that relates to your nursing diagnosis statement and ST goal/s.

Goal met or not met. Adjustments to the goal. Continue, revise or resolve POC

Assisted client to and from physical therapy. Encouraged client to participate in daily activities. Allowed rest and nap times following physical therapy. Brought client outside to get fresh air and strolled around the facility to reiterate that it is nice to have a change of scenery and interact with others outside of the client’s room. Let client do most of the movements to move in bed and while in chair by self as tolerated. Encouraged client to put on own shoes and comb hair. Left call light within reach.

Goal #1: Goal Partially Met: Client participated in the 3X weekly exercise as scheduled and maintained motivation with encouragement. Clients strength has improved along with increased tolerance to the activities. The strength gained has allowed client to require less assistance than previously noted. Client is more willing to get up and move about now since upper arms and lower leg physical limitations have been relieved....