Clinical Nursing Care Plan PDF

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Summary

clinical med sure care plan done after clinical...

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Litzy Rivera-Delgadillo Assessment CUES: Recognition of Cues Subjective:

Patient states having trouble moving the left side of her body and overall feeling weaker on the left side of the body than the right side. Objective:

When extremities were assessed patient showed a ⅖ muscle strength on both left arm and leg.

Nursing Diagnosis (NANDA Diagnostic Statement) Analysis of Cues

Goals & Expected Outcomes (S-M-A-R-T) Prioritize the Hypothesis

Nursing Interventions (Strategies/Actions) Generate Solutions/Take Actions

Impaired physical mobility related to stroke as evidenced by ⅖ left side extremities muscle strength.

Patient will perform 30 minutes of physical therapy focusing on gaining strength on the left side of the body by the end of the shift.

Assist patient with muscle exercises as given by physical therapy.

Patient will have a ⅗ left side extremities muscle strength by their discharge.

Execute passive assistive ROM exercises to all affected extremities. Let the patient accomplish tasks at his or her own pace. Do not hurry the patient. Encourage independent activity as able and safe.

Rationale for Interventions (Include Source and Page Numbers)

Adds to gaining strength of affected body parts. Exercise enhances increased venous return, prevents stiffness, and maintains muscle strength and stamina. It also avoids contracture deformation, which can build up quickly and could hinder prosthesis usage.(Nurselabs) Healthcare providers and significant others are often in a hurry and do more for patients than needed. Thereby slowing the patient’s recovery and reducing his or her confidence.(Nurselabs)

Evaluation (Client’s Response to Actions/Progress toward Achieving Outcome Goals) Evaluate the Outcomes

Patient met the short term goal of going to physical therapy and doing the exercises given in order to help her regain strength in her left side extremities. Patient has not yet met the long term goal of ⅗ left side extremities muscle strength by their discharge, but is working hard with therapy to reach this goal.

REFERENCES: Werdati, S., Pramanik, S., & Jolly, J. (2019, March 18). Impaired physical mobility – nursing diagnosis & care plan. Nurseslabs. Retrieved October 16, 2021, from https://nurseslabs.com/impaired-physical-mobility/. Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2018, November 9). Fundamentals of nursing: The art and science of person-centered nursing care (Ninth edition.). Wolters Kluwer Health.

NURSING CARE PLAN THREE NURSING DIAGNOSIS PER CARE PLAN GRADING RUBRIC

Topic Areas (A-D-O-P-I-E) Assessment Data [Identify the Cues]: ● Subjective ● Objective Nursing Diagnosis [Analyze the Cues] ● P - Problem statement/nursing diagnosis (NANDA) ● E - Etiology – 3 (or 6 for potential diagnoses) ● D (or S) – Defining characteristics (or signs/symptoms) supporting nursing diagnosis Outcomes/Goals (Plan) (1-2 goals using the S-M-A-R-T criteria) [Prioritize the Hypothesis] ● Specific —2 (or 4) ● Measurable—2 (or 4) ● Achievable—2 (or 4) ● Relevant —2 (or 4) ● Time-limited (Target for completion)—2 (or 4) Implementation (3-6/goal required) [Generate Solutions/Take Actions] ● Interventions Rationale and References ● Show evidence of source work and reasoning as a basis for interventions Evaluation Based on Planned Outcomes. You must address each of your goals separately and with separate interventions. [Evaluate the Outcomes] ● M - What would determine whether you Met your goal? ● P - What would determine whether you Partially Met your goal? ● N - What would determine when you did Not Meet your goal? References: Include a reference list constructed in APA format (papers without a reference page will not be graded). TOTAL POINTS

**A minimum score of 80% demonstrates a passing care plan.

Points Possible

Points Earned

20

20

12

12

20

20

18

18

10

10

20

20

100

100...