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Fundamentals Of Nursing Practice (NURS 206) Individual Write Up

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John Marsh
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Individual Write Up-impaired swallowing nursing diagnosis

San Diego State University

Fundamentals of Nursing Practice (NURS 206)

NANDA Nursing Diagnosis: _____Impaired physical mobility____ Related to: altered muscular function secondary to cerebral injury
As evidenced by (only use if not “risk for”) weakness on his left side and unsteady gait
PLANNING PHASE IMPLEMENTATION PHASE RATIONALE EVALUATION PHASE
Patient-centered goal (s)
Be sure goal is measurable and
includes an appropriate time
frame.
Consider: Short term goal &
long term goal
Interventions: Must be written in order of priority.
Think about all the things the RN does to help the
patient with this problem. Be specific.
Use a primary source to provide
the rational for your specific
nursing intervention. Cite
references.
Goal/s met?
1. Patient will do range of
motion exercises as ordered by
the physician during each shift
2. Patient will ambulate with
assistance as ordered by the
physician during each shift
1a. Nurse will educate patient to do the moves
slowly and carefully and emphasize that patient
shouldn’t force it if he can’t do a certain exercise
1b. Nurse will assist patient with range of motion
exercises but let the patient do some of the
exercises independently if he can.
2a. Nurse will reposition the patient every 2 hours
position the patient in proper alignment
2b. Nurse will assist the patient during ambulation
2c. Nurse will provide aids (walkers, canes, gait
belt) for the patient as needed during
2d. Nurse will observe and document patient’s
ability to ambulate throughout his length of stay
(Balderrama and Pravikoff, 2018)
2e. Nurse will assess pain if/when patient exhibits
signs and symptoms of pain during ambulation
1a and 1b. prevents muscle
degeneration, improves balance
and strength
2a. reduces the risk of pressure
ulcers and injuries due to improper
alignment (Allina Health, n.d.)
2b. reduces risk of falling and the
gait belt can guide the patient
down
2c. evaluation will help the nurse
know if the plan of care is
appropriate for the patient
2d. pain is the 5th vital sign and
it’s a priority when it comes to
improving the patient’s quality of
life
1. Goal met – patient was able to
perform ROM exercises with
minimal assistance during shift
2. Goal met — patient was able to
ambulate with a walker and gait
belt held by the nurse during shift
lOMoARcPSD|6170641

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Fundamentals Of Nursing Practice (NURS 206) Individual Write Up

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