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Careplan

NURSING DIAGNOSES EXPECTED PATIENT ASSESSMENT interventions: ACTION interventions: TEACHING interventions:
OUTCOMES (S. M. A. R. T.)
Constipation r/t weakness Pt will increase fluid intake -Assess usual pattern of -Nurse will provide pt -Teach pt to eat a
of muscles, inadequate by drinking 1.5 to 2 L of defecation, including time of with 100g of prune healthy diet with
fluid intake, decreased water daily while awake for 7 day, amount, consistency and juice daily to adequate intake of whole
autonomic nervous system days ending on 11/01/2017. frequency of stool. incorporate fiber, grains and fiber.
activity AEB Parkinsons sorbitol, and
Disease, pt drinking only -Evaluate all the medications polyphenol into pts -Teach pt keep a 7-day
720 mL of fluid in 8 hours pt is taking in order to diet and promote a diary of bowel habits to
despite being reminded, pt determine if one could have laxative effect. include date/time, length
stated my legs get sore adverse effect of constipation of time on toilet,
easily, and pt not and monitor pts water jug -Encourage pt to do consistency,
defecating in over 24 level in room to see how much physical activity like amount/frequency of
hours. they usually are drinking. walking the halls and stool, and any straining
Monitor pt fluid intake during doing waist twists. to promote pt adherence
meals too. and understanding.
-Nurse will
administer laxative or -Teach pt how to adopt
BRC bowel protocol the best posture for
drugs PRN. defecationkeep knees
slightly higher than hips,
feet flat on the floor, and
lean forward with elbows
on knees.

Risk for injury r/t tremors Pt stand up and hold onto -Monitor pts ability to -Nurse will monitor -Teach pt to do deep
in hands and legs, fatigue Rolling Walker while doing tolerate activity and use all 4 the pt while breathing exercises to
after therapy twisting side stretches/ extremities noting pulse, skin performing her help with lung expansion
sessions/walking the reaches for a minimum of 2 color, and B/P before and standing and and to help relieve pts
hallways, slowed reactions minutes three times a day at after PT sessions and while stretching exercise anxiety/ tremor intensity/
while using RW assistive 0930, 1300, and 2030 for 7 doing independent transfers. for 2 minutes three fatigue when ambulating.
times a day to ensure
device, and altered gait days ending on 11/01/2017.
-Assess pt room for any pt performs task. -Teach pt to stand up
(Parkinsons Disease).
possible hazards in the Nurse will execute slowly using the RW and
environment ie. room clutter, passive and active to sit down slowly
bed position, if the overhead ROM exercises on making sure to grab arm
lights work, or if furniture is pts legs to avoid
rests on chairs before
blocking pts walking muscle fatigue and
lowering themself to add
pathway. cramping.
extra support and to
-Nurse will monitor avoid lightheadedness.
for orthostatic
hypotension while pt
is moving and
transferring.

References
Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based
guide to planning care (11th ed.). St. Louis, MO: Elsevier.
Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing:
Assessment and management of clinical problems(10th ed.). St. Louis, MO: Elsevier, Inc.