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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


After 8 hours of nursing

intervention, client will be able INDEPENDENT
a. Perform self-care
activities within level of 1. Assess abilities and level of Aids in Done Client was able to move
own ability deficit (0–4 scale) for anticipating/planning hands and hold utensils
b. Demonstrate techniques/ while eating
performing ADLs. for meeting individual
lifestyle changes
c. Perform ROM needs.

Done Presence of Foley Catheter

. Patient may have patent and infusing well
2. Assess patient’s ability to neurogenic bladder, be
communicate the need to void inattentive, or be
and/or ability to use urinal, unable to
communicate needs in
bedpan. Take patient to the acute recovery phase,
bathroom at frequent/periodic but usually is able to
intervals for voiding if regain independent
appropriate control of this function
as recovery progresses

May provide Client was not restless

THERAPEUTIC relaxation or redirect Done
attention and reduces
1. Assist client to find position of analgesic and needs
comfort. frequency.

Enhances sense of Client shows confidence in

self-worth, promotes Done conversing with student
. nurses
2. Provide positive feedback for independence, and
efforts and accomplishments encourages patient to
continue endeavors.

These patients may Done Client’s was able to ask for

HEALTH TEACHINGS become fearful and assistance when client was
dependent, and unable to reach for food.
1. Allow client to do things on his although assistance is
own, but provide assistance as helpful in preventing
necessary frustration, it is
important for patient
to do as much as
possible for self to
maintain self-esteem
and promote recovery
imely intervention is
more likely to be
successful in
alleviating pain.

Monitoring urine
COLLABORATIVE output, including Done Urine outputMannitol 150
ASSESSMENT checking the amount cc IV bolus Q6H was given
1. Monitor Urine output provides an objective by staff nurse
measure of the client’s

To increase urine
production (diuretic). Done Urine output of 80cc/H
THERAPEUTIC It is used to treat or
1. Administer analgesics such as prevent medical
conditions that are
Mannitol as ordered by the doctor.
caused by an increase
in body fluids/water
(e.g., cerebral edema,
glaucoma, kidney

.May be necessary at
Not Done
first to aid in
. establishing regular
2. Administer suppositories and stool bowel function.

Done Client verbalized

Provides expert
understanding of health
assistance for teaching
developing a therapy
1. Consult with
physical/occupational therapists plan and identifying
special equipment


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