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  • NCP 2 - Trixie

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    James Vaughn
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    The patient reported difficulty with mobility and activity. The nursing diagnosis was activity intolerance related to immobility. The plan was to establish activity guidelines and goals with the patient and caregiver. After 24 hours of nursing intervention, the goal was for the patient to maintain good skin integrity by turning every 2 hours and preventing skin breakdown. The evaluation found the patient was able to maintain skin integrity and demonstrate techniques to prevent issues like redness or lesions.

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    Ncp 2 - Trixie

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    The patient reported difficulty with mobility and activity. The nursing diagnosis was activity intolerance related to immobility. The plan was to establish activity guidelines and goals with the patient and caregiver. After 24 hours of nursing intervention, the goal was for the patient to maintain good skin integrity by turning every 2 hours and preventing skin breakdown. The evaluation found the patient was able to maintain skin integrity and demonstrate techniques to prevent issues like redness or lesions.

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    6 views2 pages

    NCP 2 - Trixie

    Uploaded by

    James Vaughn
    The patient reported difficulty with mobility and activity. The nursing diagnosis was activity intolerance related to immobility. The plan was to establish activity guidelines and goals with the patient and caregiver. After 24 hours of nursing intervention, the goal was for the patient to maintain good skin integrity by turning every 2 hours and preventing skin breakdown. The evaluation found the patient was able to maintain skin integrity and demonstrate techniques to prevent issues like redness or lesions.

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    Attribution Non-Commercial (BY-NC)
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    of 2

    Assessme nt Subjective:

    Nursing Diagnos is %ctivity intoleran ce related to i""obilit y

    Planning

    Intervention

    Rationale

    Evaluation

    Nahirapan ako as verbalized by the patient.

    %!ter ' hours o! nursin# intervention( the client &ill be able to "aintain a #ood skin inte#rity as evidenced by: a.) absence o! redness over bony pro"inences* b.) presence o! skin intact such as absence o! lesions* and c.) de"onstrate behaviors$tech ni+ues to prevent skin breakdo&n such as turnin# to sides at least every , hours.

    - -stablish #uidelines and #oals o! activity &ith the clients and care#iver.

    Objective: - Decreased
    RO on the le!t side o! the body.

    -Di!!iculty in per!or"in# so"e #ross$!ine "otor skills

    - otivation is enhanced i! the client participates in #oal settin#. Dependin# on the etiolo#ical !actors o! activity intolerance( so"e clients "ay be able to live independentl y and &ork outside the ho"e. Other clients &ith chronic debilitatin# disease "ay re"ain. - /his pro"otes a sa!e environ"ent. - /his opti"izes circulation to all tissues and relieves pressure.

    %!ter ' hours o! nursin# intervention ( the client &as able to "aintain a #ood skin inte#rit y as evidenced by: a.) absence o! redness over bony pro"inenc es* b.) presence o! skin intact such as absence o! lesions* and c.) de"onstrat e behaviors$t echni+ues to prevent skin breakdo&n such as turnin# to sides at least every

    -%ssistance is needed &hen per!or"in# activities o! daily livin#

    -.eep side rails up and bed in lo& position. - /urn and position every , hours or as needed.

    De"onstrat es di!!iculty &ith "obility

    and activity - 4se prophylactic antipressure devices as appropriate. - -ncoura#e cou#hin# and deep-breathin# e5ercises. -3er!or" passive or active assistive RO e5ercises to all e5tre"ities.

    -0eakness in the le!t side o! the body -Dryness o! skin -Doctors order 12R &ithout 23R

    - /his prevents tissue breakdo&n.

    , hours.

    - /hese prevent buildup o! secretions.

    --5ercise pro"otes increased venous return( prevents sti!!ness( and "aintains "uscle stren#th and endurance.

    --ncoura#e to continue 3hysical therapy

    -3hysical therapists can provide specialized services !or activity

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