Defining characteristics
Diagnosis
Subjective
“My right knee stiff for 5-
15 minutes most morning
and often feels stiff after
prolonged sitting.”-as
verbalized by the patient
Objectives
 PR: 83 beats/min
 BP: 140/90
 Range of motion on
the left knee is full
 Mild effusion felt
Nursing Outcome Identification Nursing Interventions Rationale Evaluation
Short Term: Independent Short term:
Impaired physical After 5 days of nursing Goals met. After 4 days of
mobility related intervention, the client will be effective nursing intervention,
osteoarthritis able to demonstrate  Assess the client’s
 To assess for indicators the client is able to
secondary to joint techniques/behaviors that posture and gait.
of a decreased ability to demonstrate
stiffness. enable resumption of ambulate and move
(Nurse’s Pocket activities. techniques/behaviors that
purposefully.
Guide 15th edition) enable resumption of activities.
 Asses the client’s
 Excessive weight may
Rationale weight.
add stress to painful
Osteoarthritis can joints.
degrade cartilage, Long Term
Long Term:
change bone After 2 weeks of nursing  Goals met. After 2 week of
 Encourage self-care
shape and cause intervention, the client will be  To improve muscle
activities to the nursing intervention, the client
inflammation, able to maintain or increase client’s. strength and circulation, is able to maintain or increase
resulting in pain, the strength and function of enhance client to control
stiffness and loss the strength and function of
affected body. in situation and promote
of mobility. self-directed wellness. affected body.
-improved physical mobility of  Assess range of - improved physical mobility of
the clients motion in all joints, the clients
 To prevent progressive
comparing active loss of ROM.
and passive ROM.
 Encourage client to
maintain upright and
erect posture when  To maximize joint
sitting, standing and function, maintain
walking mobility
 Provide patient with
sample time to
 perform mobility  To promote optimal
related task level of function.

Dependent
Administer medication
such as:

 Adequate calcium  Vitamin D promotes

Vitamin D intake. calcium absorption by the
body to enable bone
growth and repair.

Collaborative:

 Refers to physician,  To determine potential

physical therapy for improvement and
specialist. direction for therapies.
Defining characteristics Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation

Subjective Long term Independent

Acute Pain related to
“” as verbalized by the Dependent To identify the patient’s Goals met, patient
patient needs or unspoken behavioral cues were
concerns observed
Objectives

Temperature: 36.5 To have a successful

degree Celsius interaction (clarity helps Goals met, interaction was
BP: 130/90 mmHg patients to understand the successful and the message
PR: 70 bpm message) was understood by the
RR: 23 cpm patient
Short Term To remove distractions as
Disoriented, anorexic,
we interact with the patient. Goals unmet, external
slurring of words, irritable
(patients will interpret the noises was not fully
message effectively if the eliminated as the patient
surroundings is calm) was not on the private room

To understand what the

patient is trying to tell you
Goals met, patient was
understood because of
patience
For doctors to have a
detailed images of organs

Prevents the breakdown of a Results are in.

chemical called
acetylcholine
Goals met, medications
Enhances cholinergic
were administered following
function
the correct timing
Modifies the humoral
mechanisms of headache