HNN112 Nursing Care Plan Quality and Safety: Nursing Practice 1 (Deakin University)

HNN112 Nursing Care Plan Quality and Safety: Nursing Practice 1 (Deakin University) Problem: Impaired mobility (will reduce the ability of ADLs) r/t to pain/pain from surgical wound r/t to imposed bed rest r/t to injury r/t to fracture Goal: Patient performs physical activity independently Patient demonstrate the use of adaptive device to increase mobility Assessment: Assess the strength to perform ROM (range of motion) to all joints Rationale: this assessment provides data on extent of any physical problems and guides therapy Monitor nutritional needs as they relate to immobility Rationale: good nutrition also gives required energy for participating in an exercise or rehabilitative activities. Assess input and output record and nutritional pattern. lOMoARcPSD| Rationale: Pressure ulcers build up more rapidly in patients with a nutritional insufficiency. Note elimination status (e.g., usual pattern, present patterns, signs of constipation). Rationale:Immobility promotes constipation Intervention: 1. Present a safe environment: bed rails up, bed in down position, important items close by. Rationale: these measures promotes a safe, secure environment and may reduce risk of falls. 2. Assist as required (ensure ADLs are complete) Rationale: assist clients in ADLs can lower the risk of fall, also gives him a support. 3. Assist patient for muscle exercises as able Rationale: enhance muscle strengthens 4. Turn and position the patient every 2 hours or as needed. Rationale: Position changes optimize circulation to all tissues and relieve lOMoARcPSD| pressure. 5. Administrate analgesia (e.g. paracetamol) to control the pain in order to increase mobility Rationale: Non-opioid analgesia inhibits the central PGs production in the hypothalamus and modulation of inhibitory descending pathways. Evaluation Patient improve the ability of ADLs, nil further issues Nil complain any pain Patient use safety measures to minimize potential for injury Patient mobilize safely Problem: Acute pain r/t to irritation of skin, caused by inflammation surgery accident muscle strain from excessive coughing Goal: Reduce pain, pain control at a level less than 3 to 4 on a rating scale lOMoARcPSD| of 0 to 10. Assessment: Assess the effectiveness of analgesia Rationale: increased pain may indicate worsening condition Assess for signs and symptoms relating to pain Rationale: an increase in BP, HR, and Temp may be present in a patient with acute pain. The patient’s skin may be pale and cool to touch. Intervention: Provide analgesics as ordered, evaluating the effectiveness and inspecting for any s/s of adverse effects