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Assessment Nursing RATIONALE Planning Interventions Rationale Evaluation


Risk for Immobility, which After 1-2 hours of No. evaluation.

Impaired leads to pressure, nursing
Skin shear, and friction, is intervention the
Objective: Integrity r/t the factor most likely client and the
 Dx: prolonged to put an individual at relatives will be
CVD bed rest risk for altered skin able to verbalize
infar and altered integrity. Advanced understanding of
ct ® circulation . age; the normal loss individual factors
prob. of elasticity; that contribute
inadequate nutrition; to possibility of
 c standby environmental skin integrity
O2 @ moisture, especially impairment and
bedside from incontinence; take steps to  Place the  to prevent backaches
and vascular correct the pt in a or muscle aches.
 c good insufficiency situation. comfortable
capillary potentiate the effects position  to note any significant
refill in 2-3 of pressure and As evidence by: changes that may be
hasten the
 Take and
secs. record vital brought about by the
development of skin  understan disease
breakdown. Groups of ding the
 c body
persons with the situation.
highest risk for  patient’s  Elderly patients’ skin is
altered skin integrity skin normally less elastic
2 weeks
are the spinal cord remain and has less moisture,
bedridden  Determine
injured, those who intact making for higher risk
are confined to bed or age.
 on CBR  no of skin impairment.
wheelchair for redness
w/o BRP prolonged periods of over bony
time, those with prominen
 c limited edema, and those ces
ROM who have altered
sensation that
 dry skin triggers the normal
protective weight  Healthy skin varies
shifting. Pressure from individual to
relief and pressure individual, but should
reduction devices for  Assess
general have good turgor, feel
the prevention of skin warm and dry to the
breakdown include a condition of
skin. touch, be free of
wide range of impairment, and have
surfaces, specialty quick capillary refill (<6
beds and mattresses, seconds).
and other devices.

Nursing vol. 10th ed.
Brunner & Suddarths,
pg 1567)

Assessment Nursing Dx RATIONALE Goals Intervention Rationale Evaluation

Subjective: CVD can be
Impaired caused by After 4 hrs of nursing After 4 hrs of nursing
physical an occlusion in intervention, the intervention, the
Objective: mobility r/t the relatives will be relative are able to
 Limited neuromuscular blood flow. This able to participate in participate in
range damage can therapeutic regimen therapeutic regimen
of motion involvement lead to ↓O2 and as evidence by: as evidence by:
(client can’t the Independent: Independent:
fully extend cause failure to  Verbalization  Determine  To  Verbalization
his right arm nourish the understanding of degree of establish understanding of
and hold up tissues at the situation and Immobility compara the situation and
his right the capillary therapy tive therapy
shoulder) level and  Able to baseline  Able to
 Limited that can cause participate  Observe  To note participate
ability neuromuscular in the interventions movement any in the interventions
and difficulty damage w/c rendered by the when client is incongru rendered by the
to perform can cause nurse unaware ence nurse
gross motor impaired with the
skills like physical reports
extending and mobility of
lifting of the abilities
right arms Medical-  Support  Reduce
Surgical affected part risk of
 Slowed Nursing, with pillows pressure
Movement left vol.2,9th
arm edition,  Give rest  To help
 Dx: CVD Brunner & periods to reduce
infarct ® Suddarths, Activities
prob. page 768 ) fatigue
 intubated and O2
since  Encourage demand
4/23/10 adequate  ↑ energy
 FIO2- @ 2- fluids and right producti
3LPM TV- diet on
320, RR- as necessary to
20, PF-60 the (Nursing Care
client Plan, 6th
pg. 879)

Assessment Nursing Dx RATIONALE Goals Intervention Rationale Evaluation

SUBJECTIVE: Impaired A CVD, which may After 2 hours of After 2 hours of
verbal nursing interventions,
be caused by, nursing intervention
communicati the client will
on hemorrhage, establish method of the goal was met the
• Difficult related to communication in
thrombus, client established
y loss of which needs can be
producing oral muscle embolism or expressed. method of
speech. tone control.
vasospasm, can >Monitored vital >Establishes communication in
• Facial As evidence by:
paralysis. result in a local signs with baseline data for which needs are
• Muscle and area of cell death,  Established emphasis to BP. review of existing expressed
facial tension eye contact
• restless called infarct. It is conditions. As evidenced by :
noted caused by a lack while
• Un able communicatin
of blood supply >Provided an  Established
communicate which is then g with others atmosphere of >Impaired ability eye contact
• CVD  Used paper
surrounded by an acceptance and to communicate while
area of cells that and pen to privacy through spontaneously is communicatin
are secondarily express needs speaking slowly frustrating and g with others
affected. Since and in a normal embarrassing.  Used paper
symptoms depend tone, not forcing Nursing actions and pen to
on the location of the client to should focus on express needs
the stroke and communicate. decreasing the
size of the infarct, tension and
it could involve conveying an
the brain’s understanding of
Brocca’s area, how difficult the
which is primary situation must be
responsible for for the client
communication >Taught
through facial techniques to
expressions and improve speech >Deliberate
speech. By by initially asking actions can be
causing damage questions that taken to improve
to this area, the client can answer speech. As the
patient’s with a “yes” or client’s speech
communicating “no”. improves, his
skills are greatly confidence will
altered and increase and she
affected. will make more
>Used strategies attempts at
to improve the speaking.
(Medical- Surgical client’s >Improving the
Nursing, vol.2,9th
comprehension client’s
edition, Brunner &
Suddarths, page by using touch comprehension
1259 )
and behavior to can help to
communicate decrease
calmness and frustration and
adding other non increase trust.
– verbal methods Clients with
of aphasia can
communication correctly interpret
such as pointing tone of voice.
or using flash
cards for basic
needs; using
pantomime; or
using paper and
>Involved the >Enhances
significant others participation and
in the plan of commitment to
care. plan.

>Educated >Imparts thought

relatives to and answers the
establish a needs of the client
method of with lessened
communication difficulty.
through sign (Nursing Care Plan,
language. 6th edition,
Gulanick/Myers pg.