Risk Assessment of Juana

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Independent:
Before being Identify potential Disuse syndrome After being
Risk for
Prolonged Bed discharge she concerns, including can include discharged the
Rest due to being Disuse should be able cognition, mobility, and muscle and bone patient displays
shifted to an Syndrome to display intact exercise status atrophy, stiffening intact skin and
Intensive care skin and tissues of joints, brittle tissues and achieve
unit having an or achieve bones, reduction timely wound
unavoidable timely wound of healing. She also
musculoskeletal healing. cardiopulmonary maintains or
inactivity. Maintain or function, loss of reestablish effective
reestablish red blood cells elimination patterns.
effective (RBCs), Demonstrate
elimination decreased sex absence of
patterns. hormones, pulmonary
Demonstrate decreased congestion with
absence of resistance to breath sounds clear.
pulmonary infections, Demonstrate
congestion with increased adequate peripheral
breath sounds proportion of perfusion with stable
clear. body fat in vital signs, skin
Demonstrate relation to muscle warm and dry,
adequate mass, and palpable peripheral
peripheral chemical pulses.
perfusion with changes in the More importantly she
stable vital brain, which is able to express
signs, skin adversely impact sense of control over
warm and dry, the client’s the present situation
palpable activities of daily and potential
peripheral living (ADLs), outcome.
pulses. Express social life, and Recognize and
sense of control quality of life. incorporate change
over the present into self-concept in
situation and Review psychological Potential accurate manner
potential assessment of client’s problems that without negative
outcome. emotional status. may arise from self-esteem.
Recognize and presence of
incorporate condition need to
change into be identified and
self-concept in dealt with to
accurate avoid further
manner without debilitation.
negative self- Common
esteem. associated
psychological
changes include
depression,
anxiety, and
avoidance
behaviors.

Inspect skin on a Monitor skin over

frequent basis, noting bony
changes prominences.

Encourage intake of To reduce risk of

adequate fluids, urinary infections.
including water and
cranberry juice.

Provide skin care daily To stimulate

and prn, drying well and circulation
using gentle massage
and lotion

Monitor breath sounds For early

and characteristics of detection of
secretions complications
(e.g., atelectasis,
pneumonia).
Collaborative:
Together with a Treatment may
physician review be required for
therapeutic regimen underlying
condition(s),
stress
management,
Risk Assessment of Juana

medications,
therapies, and
needed lifestyle
changes.

Identify need and use of To assist with

supportive devices safe mobility and
functional
independence