Care Plan

Topics: Nursing care plan, Pain, Suffering Pages: 8 (1748 words) Published: April 10, 2014


NRS 200 – Health Restoration I
In-Depth Clinical Practicum Guide

IN-DEPTH CLINICAL PRACTICUM NURSING CARE PLAN
Nursing Diagnosis: Impaired physical mobility related to decreased muscle strength and endurance secondary to bilateral knee surgery Goal: Pt will report increased strength and endurance of lower extremities (knees) Expected Outcomes/Goals

Nursing Interventions
Rationale with Cited Sources
Evaluation of Outcomes/Goals
1. Pt will demonstrate the use of adaptive devices to increase mobility by end of shift. 2. Pt will evaluate pain and quality of management 3 times by end of shift. 3. Pt will demonstrate increased mobility in knees by end of shift. Outcome goal 1

1. Evaluate need for assistive devices.
2. Provide walker every time pt is up and out of bed. Re-enforce proper technique for using walker. 3. Teach pt about variety of assisted devices available for use at home Outcome/goal 2
1. Encourage pt to monitor pain level q2hrs (outside of mandatory rating for pain meds) using 0-10 pain scale. 2. Encourage pt to describe pain: location, intensity, and characteristics 3. Encourage pt to evaluate what did and didn’t work for pain relief. Outcome/goal 3

1.Encourage the highest level of mobility
2. Explain the importance of the pt boosting herself to do the most she can. 3. Evaluate safety of the immediate environment.
Rationale for outcome/goal 1 interventions
1. “Assistive devices can improve self care ability and enhance the client’s sense of control…,”(Lippincott, Williams, and Wilkins, pp 370, 2009). 2. “Assistive devices can improve self care ability and enhance the client’s sense of control…,” (Lippincott, Williams, and Wilkins, pp 370, 2009). 3. “A comfortable, secure environment can…enhance self care abilities,” (Lippincott, Williams, and Wilkins, pp 370, 2009). Rationale for outcome/goal 2 interventions

1. “The first step in pain assessment is to determine if the client can provide a self report. Ask the client to rate pain intensity or select descriptors of pain intensity using a valid and reliable self report pain tool” (McCaffery, Herr and Pasero, 2011 in Lippincott, Williams, and Wilkins, pp 542, 2009 ). 2. “Verbalization allows sharing and provides the nurse with an opportunity to correct misconception,”(Lippincott, Williams, and Wilkins, pp 104, 2009). 3. “Less pain medication generally is required if administered early,” (Lippincott, Williams, and Wilkins, pp 104, 2009). Rationale for outcome/goal 3 interventions

1. “Regular movement relieves constant pressure over boney prominence” (Berlowitz, 2007 in Lippincott, Williams, and Wilkins, pp 500, 2009). 2. “…recover quickly from setbacks, and ultimately are likely to achieve their personal goals, (http://serc.carleton.edu, 2013). 3. “Obstacles such as throw rugs, children toys, pets, and others can further impede one’s ability to ambulate safely” (www.1us.slsevierhealth.com, 2013). Include date/time of observation

1. Goal met on 10/03/13 at 14:15
Pt was able to properly use a walker to help he r walk
2. Goal met on 10/03/13 at 14:15
Pt promptly stated pain level and if it was properly managed before all 3 PT/ OT sessions. 3.Goal met on 10/03/13 at 14:15
Pt walked hallway with minimal assistance before end of shift.

References
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 370)
(5th ed.) . Philadelphia, PA
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 542)
(5th ed.) . Philadelphia, PA
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 104)
(5th ed.) . Philadelphia, PA
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 500)
(5th ed.) . Philadelphia, PA
Self-efficacy: Helping...

References: Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 122)
(5th ed.)
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 755)
(5th ed.)
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 744)
(5th ed.)
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 66)
(5th ed.)
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 82)
(5th ed.)
Lipincott, J.B., Williams, Wilkins (2009) . Nursing care plans & documentation: Nursing diagnosis and collaborative problems. (pp 69)
(5th ed.)
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