Nursing Care Plan

1318 WordsNov 18, 20126 Pages
Nursing Care Plan Assessment equals Data Collection + Analysis | Nursing Diagnosis – Actual/Potential | Nursing Goal(SMART) | Nursing Interventions/ActionsInclude Rationale/Reference | Evaluation | Female Age : 85Code status: Full Code initially but changed to DNR on 14/Jan-2012Primary diagnosis: PancytopeniaReason for Hospital Admission: Fall at home. Allergy: PenicillinMedical History: Pacemaker, Hypertension, Fall at home, Bradycardia, Hyperlipidemia.Neurological: Alert, Oriented x 4.Diet as ToleratedActivity as tolerated.Does not want to do physiotherapy.Would prefer to remain in bed.Will only move her arms and legs and adjust as needed. | Activity Intolerance related to weakness, bed rest and immobility as evidenced by client…show more content…
Encourage client to do exercises and activity as tolerated to maintain muscle strength and joint flexibility. Rationale: A routine of exercises such as Tai chi can enhance balance and improve overall muscle strength (Best Practice Guideline, Rec. 2.1, 2005).5. Educate client to stay in the lower level of house such as bedroom/washroom or everything in one floor. Rationale: Having all daily required amenities nearby will reduce client’s risk of falling. (Kozier, pg 774, 2010).6. Increase client’s awareness by highlighting the risk factors associated with falls within home; removing unsafe objects.Rationale: Risk factors such as clutter, unsecure rugs, extra loose tripping clothing and inadequate lighting hampers the motivation for mobility (Kozier, pg 774, 2010). 1. Creating a therapeutic nurse-client relationship by listening attentively and increasing her positivity by talking about her past pleasant experiences.Rationale: Encourage client to share feeling and reflecting on past accomplishments, positive memories and significant milestones (Day, 2010, pg. 434).2. Encourage client to become involved in activities on the unit like interacting with staff, other clients, participating in therapy and recreational activities.Rationale: This will help distract her mind from a preoccupation with her illness (White, 2005, pg. 1326).3. Provide things to do when client is feeling down, like, crossword puzzle, reading books, watching

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