Simple Care Plan Lloyd Bennett PDF

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Summary

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Description

Nursing Diagnosis

Objective /Goals SHORT and LONG term (Relate to the diagnose)

Patient: Lloyd Bennet

Nursing diagnosis Short Term Goals:  Patient will report any increase in activity tolerance post-surgery

NANDA DX: 1. Activity intolerance related to inability to change position as evidenced by dizziness Pertinent Labs  Complete blood count  Imaging studies (Xray, MRI, CT scan etc.) Pertinent Assessment  Range of motion  Neurological  Integumentary  Pain level  Respiratory (postsurgery)

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Patient will demonstrate a decrease in physiological signs of intolerance. Long Term Goals:  Patient will have increased strength and function of affected limb

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Patient will participate in ADLs/rehabilitation program as needed

Interventions

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Assess the patient’s ability to perform tasks and any changes with activities such as standing, sitting, moving around Assess patient’s neurological status for any headache, dizziness, vision changes or worsening signs and symptoms especially when the patient is performing tasks Educate patient on their condition and interventions; such as slow movements stimulating range of motion activities with rest periods that could be done in order to slowly return to tolerance

Rationale (Evidenced based reason for your interventions)  “Providing a clear explanation of all available treatment options enables the patient to make knowledgeable healthcare decisions and take an active role in their care” (Hoffman & Sullivan, 2020)

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Neurological changes or deficits in pupils, grips, foot pushes, facial droop, and speech may be signs of CNS embolization (Hoffman & Sullivan, 2020) “Exercise/physical therapy promotes movement, muscle strength, and return to preinjury functioning” (Hoffman & Sullivan, 2020)

Evaluation for each Intervention 

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The patient will show tolerance during physical activity and understand interventions to be done such as sitting down for a few minutes before standing. The patient will remain free of any alarming neurological signs such as dizziness when performing activities The patient will describe the capability to show activities of daily living and will know about techniques to reduce activity intolerance

Resources

Hoffman, J. J., & Sullivan, N. J. (2020). Davis advantage for medical-surgical nursing: making connections to practice. Philadelphia: F.A. Davis...