Nursing Care Plan

NURSING CARE PLAN

NURSING DIAGNOSIS: Self-Care deficit may be related to loss of muscle control/coordination evidenced by: a. impaired ability to put on/take off clothing b. difficulty completing toileting tasks c. inability to perform ROM GOALS OF CARE After 8 hours of nursing intervention, client will be able to: . a. Perform self-care activities within level of own ability b. Demonstrate techniques/ lifestyle changes c. Perform ROM

NURSING INTERVENTION

RATONALE

EVALUATION

CLIENT’S RESPONSE

INDEPENDENT ASSESSMENT 1.

Assess abilities and level of deficit (0–4 scale) for performing ADLs.

. 2.

Assess patient’s ability to communicate the need to void and/or ability to use urinal, bedpan. Take patient to the bathroom at frequent/periodic intervals for voiding if appropriate

THERAPEUTIC 1.

Assist client to find position of comfort.

. 2.

Provide positive feedback for efforts and accomplishments

HEALTH TEACHINGS 1.

Allow client to do things on his own, but provide assistance as necessary

Aids in anticipating/planning for meeting individual needs.

Patient may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses

May provide relaxation or redirect attention and reduces analgesic and needs frequency.

Enhances sense of self-worth, promotes independence, and encourages patient to continue endeavors.

These patients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for patient to do as much as

Done

Client was able to move hands and hold utensils while eating

Done

Presence of Foley Catheter patent and infusing well

Done

Done

Done

Client was not restless

Client shows confidence in conversing with student nurses

Client’s was able to ask for assistance when client was unable to reach for food.

possible for self to maintain self-esteem and promote recovery imely intervention is more likely to be successful in alleviating pain.

COLLABORATIVE ASSESSMENT 1. Monitor Urine output

THERAPEUTIC 1. Administer analgesics such as Mannitol as ordered by the doctor.

. 2.

Administer suppositories and stool softeners

HEALTH TEACHING 1. Consult with physical/occupational therapists

Evaluation: After 8 hours of nursing intervention, client was able to: • Perform self-care activities within level of own ability • Demonstrate techniques/ lifestyle changes • Perform ROM

Monitoring urine output, including checking the amount provides an objective measure of the client’s coordination To increase urine production (diuretic). It is used to treat or prevent medical conditions that are caused by an increase in body fluids/water (e.g., cerebral edema, glaucoma, kidney failure)

.May be necessary at first to aid in establishing regular bowel function.

Provides expert assistance for developing a therapy plan and identifying special equipment needs.

Done

Urine outputMannitol 150 cc IV bolus Q6H was given by staff nurse

Done

Urine output of 80cc/H

Not Done

Done

Client verbalized understanding of health teaching