Concept Mapping Page2 Nursing Diagnosis:

3. Self care deficit related to cognative decline. Impaired ability to perform or complete feeding, bathing/hygiene, dressing and grooming, or toileting activities for oneself on a temporary, permanent, or progressing basis. Bed rest with bathroom privileges, up with assistance. Acute confusion. Impaired physical mobility. Weakness.

Goal: Outcomes:

To improve in ability to perform self-care activities. (ADL's)

1. To be able to complete toileting tasks. 2. To be able to utilize support services.

Nursing Interventions

Evaluation (Clients Response) to the Nursing Interventions

1. Determine hygienic needs and provide assistance as needed 1. The patient and his family collaborated and assisted the Nurse in with activities, including care of hair, nails, and skin; brushing identifying what ADL's the patient would need assistance with. A teeth, and cleaning glasses. prioritized list was made and accepted by the patient.
Rationale: As the disease progresses, basic hygienic needs may be forgotten. Infection, gum disease, disheveled appearance, or harm may occur when client or caregivers become frustrated, irritated, or intimidated by degree of care required. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

2. Inspect skin regularly.

Rationale: Presence of such lesions as ecchymoses, lacerations, or rashes may require treatment as well as signal the need for closer monitoring and protective interventions. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

2.

The patient's skin integrity is intact and free from any wounds.

3. Supervise but allow as much autonomy as possible.

Rationale: Eases the frustration over lost independence. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

3. Patient successfully shows willingness to do things on his own but does communicateboth verbally and non verbally when he needs assistance.

4. Allot plenty of time to perform tasks.

Rationale: Tasks that were once easy, such as dressing or bathing, are now complicated by decreased motor skills or cognitive and physical changes. Time and patience can reduce chaos resulting from trying to hasten this process. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

4. Patient successfully completed some of his self care when allowed alloted time and given patience and the resources needed to complete tasks.

5. Be alert to underlying meaning of verbal statements.

Rationale: May direct a question to another, such as, Are you cold? meaning I am cold and need additional clothing. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

5. Patient's ability to communicate information pertinent to his self care is adequate to understand and discern.

Impression
The goals set for this patient were successfully met with the patient showing signs of Improved Self Care.

Concept Mapping Page2 Nursing Diagnosis:

3. Self care deficit related to cognative decline. Impaired ability to perform or complete feeding, bathing/hygiene, dressing and grooming, or toileting activities for oneself on a temporary, permanent, or progressing basis. Bed rest with bathroom privileges, up with assistance. Acute confusion. Impaired physical mobility. Weakness.

Goal: Outcomes:

To improve in ability to perform self-care activities. (ADL's)

1. To be able to complete toileting tasks. 2. To be able to utilize support services.

Nursing Interventions

Evaluation (Clients Response) to the Nursing Interventions

1. Determine hygienic needs and provide assistance as needed 1. The patient and his family collaborated and assisted the Nurse in with activities, including care of hair, nails, and skin; brushing identifying what ADL's the patient would need assistance with. A teeth, and cleaning glasses. prioritized list was made and accepted by the patient.
Rationale: As the disease progresses, basic hygienic needs may be forgotten. Infection, gum disease, disheveled appearance, or harm may occur when client or caregivers become frustrated, irritated, or intimidated by degree of care required. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

2. Inspect skin regularly.

Rationale: Presence of such lesions as ecchymoses, lacerations, or rashes may require treatment as well as signal the need for closer monitoring and protective interventions. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

2.

The patient's skin integrity is intact and free from any wounds.

3. Supervise but allow as much autonomy as possible.

Rationale: Eases the frustration over lost independence. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

3. Patient successfully shows willingness to do things on his own but does communicateboth verbally and non verbally when he needs assistance.

4. Allot plenty of time to perform tasks.

Rationale: Tasks that were once easy, such as dressing or bathing, are now complicated by decreased motor skills or cognitive and physical changes. Time and patience can reduce chaos resulting from trying to hasten this process. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

4. Patient successfully completed some of his self care when allowed alloted time and given patience and the resources needed to complete tasks.

5. Be alert to underlying meaning of verbal statements.

Rationale: May direct a question to another, such as, Are you cold? meaning I am cold and need additional clothing. http://www.enurse-careplan.com/2011/08/self-care-deficit-nursing-care-planncp.html

5. Patient's ability to communicate information pertinent to his self care is adequate to understand and discern.

Impression
The goals set for this patient were successfully met with the patient showing signs of Improved Self Care.

Concept Mapping Page2 Nursing Diagnosis:

2. Impaired Physical mobility. A limitation in independent, purposeful physical movement of the body of one or more extremities. Bed rest up with assistance. Patient complains of dizziness and weakness upon standing. The Patient will have Improved physical mobility 1. The patient will sit in a chair twice a day for 30 minutes by discharge date. 2. The patient will ambulate to the end of the hall and back with assistance by discharge.

Goal: Outcomes:

Nursing Interventions
1. The nurse will assist patient to chair twice a day for 30 minutes each time.
Rationale: Gradual activity progression prevents a sudden increase in cardiac workload. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

Evaluation (Clients Response) to the Nursing Interventions

2. The nurse will assist to ambulate patient to the end of the hall and back once a day.
Rationale: Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

3.

Nurse will assist patient to bathroom when needed.

Rationale: Providing assistance only as needed encourages independence in performing activities. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

4. Nurse will assist patient with Range of Motion exercises one time a day.
Rationale: Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

5. Nurse will monitor vital signs after exertion for base line differences.
Rationale: The stated parameters are helpful in assessing physiologic responses to the stress of activity http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

Impression

ent of the body of nd weakness upon

e.

the Nursing

Concept Mapping Page2 Nursing Diagnosis:

1. Impaired Physical mobility. A limitation in independent, purposeful physical movement of the body of one or more extremities. Bed rest up with assistance. Vertigo, dizziness, confusion,weakness.

Goal: Outcomes:

The Patient will have Improved physical mobility 1. The patient will sit in a chair twice a day for 30 minutes by discharge date. 2. The patient will ambulate to the end of the hall and back with assistance by discharge.

Nursing Interventions
1. The nurse will assist patient to chair twice a day for 30 minutes each time.
Rationale: Gradual activity progression prevents a sudden increase in cardiac workload. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

Evaluation (Clients Response) to the Nursing Interventions

1. The patient successfully sat in the chair by his bed for 30 minutes two times daily.

2. The nurse will assist to ambulate patient to the end of the 2. The patient successfully ambulated to the end of the hall and hall and back once a day. back to the room with nurses help and aid of walker.
Rationale: Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

3.

Nurse will assist patient to bathroom when needed.

Rationale: Providing assistance only as needed encourages independence in performing activities. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

3. Patient successfully ambulated to the bathroom with the assistance of the nurse andfamily.

4. Nurse will assist patient with Range of Motion exercises one time a day.
Rationale: Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

4. Patient successfully completed Range of Motion exercises with the assistance and guidance of the Nurse.

5. Nurse will monitor vital signs after exertion for base line differences.
Rationale: The stated parameters are helpful in assessing physiologic responses to the stress of activity http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

5. Patient's vital signs were successfully monitored by the Nurse before and after physical mobility and exertion.

Impression
The goals set for this patient were successfully met with the patient showing signs of Improved Physical Mobility.

Concept Mapping Page2 Nursing Diagnosis:

1. Impaired Physical mobility. A limitation in independent, purposeful physical movement of the body of one or more extremities. Bed rest up with assistance. Vertigo, dizziness, confusion,weakness.

Goal: Outcomes:

The Patient will have Improved physical mobility 1. The patient will sit in a chair twice a day for 30 minutes by discharge date. 2. The patient will ambulate to the end of the hall and back with assistance by discharge.

Nursing Interventions
1. The nurse will assist patient to chair twice a day for 30 minutes each time.
Rationale: Gradual activity progression prevents a sudden increase in cardiac workload. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

Evaluation (Clients Response) to the Nursing Interventions

1. The patient successfully sat in the chair by his bed for 30 minutes two times daily.

2. The nurse will assist to ambulate patient to the end of the 2. The patient successfully ambulated to the end of the hall and hall and back once a day. back to the room with nurses help and aid of walker.
Rationale: Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

3.

Nurse will assist patient to bathroom when needed.

Rationale: Providing assistance only as needed encourages independence in performing activities. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

3. Patient successfully ambulated to the bathroom with the assistance of the nurse andfamily.

4. Nurse will assist patient with Range of Motion exercises one time a day.
Rationale: Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

4. Patient successfully completed Range of Motion exercises with the assistance and guidance of the Nurse.

5. Nurse will monitor vital signs after exertion for base line differences.
Rationale: The stated parameters are helpful in assessing physiologic responses to the stress of activity http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

5. Patient's vital signs were successfully monitored by the Nurse before and after physical mobility and exertion.

Impression
The goals set for this patient were successfully met with the patient showing signs of Improved Physical Mobility.

Concept Mapping Page2 Nursing Diagnosis:

2. Acute Confusion. Abrupt onset of reversible disturbances of consciousness, attention, cognition and perception that develop over a short period of time. Alert to person only. Neurological checks every 4 hours. Low Red blood cells in turn low oxygenation of blood to brain.

Goal: Outcomes:

Patient will have improved mental cognitive abilities.

1. Patient will be alert to name. 2. Patient will be alert to place.

Nursing Interventions
1. Observe for changes in behavior and mentation: lethargy, confusion, drowsiness, slowing or slurring of speech, and irritability. Arouse client at intervals, as indicated.
Rationale: Ongoing assessment of behavior and mental status is important because of fluctuating nature of hepatic encephalopathy or impending hepatic coma. http://www.enurse-careplan.com/2011/04/risk-for-acute-confusion-nursingcare.html

Evaluation (Clients Response) to the Nursing Interventions

1. The patient arouses easily and seems to be stable in behavior. Patient is alert to place and time at times.

2. Review current medication regimen.

Rationale: Adverse drug reactions or interactions may potentiate or exacerbate confusion. http://www.enurse-careplan.com/2011/04/risk-for-acute-confusion-nursingcare.html

2. The patient seems to be taking some medications that need to be discussed with the Doctor. (I discovered this doing my medication sheet and if I was a Nurse I would contact the Doctor because his antipsychotic is not for older patients with dementia) 3. Patient successfully reorients to time, place,person and situation for short periods of time.

3. Reorient to time, place, person, and situation, as needed.

Rationale: Assists in maintaining reality orientation, reducing confusion and anxiety. http://www.enurse-careplan.com/2011/04/risk-for-acute-confusion-nursingcare.html

4. Consult with Client's family about clients usual behavior and mentation.
Rationale: Provides baseline for comparison of current status. http://www.enurse-careplan.com/2011/04/risk-for-acute-confusion-nursingcare.html

4. Patient successfully alerts to family. According to family, patient still has some cognative deficits from patient's normal baseline.

5. Provide continuity of care. If possible, assign same nurse over 5. Patient remembers some of the Nurses and recognizes them when they come into patient's room. a period of time.
Rationale: Familiarity provides reassurance, aids in reducing anxiety, and provides a more accurate documentation of subtle changes. http://www.enurse-careplan.com/2011/04/risk-for-acute-confusion-nursingcare.html

Impression
The goal is met because the patient is showing signs of improved cognative deficits and alert to person, place and time at intervals throught the day.

Concept Mapping Page2 Nursing Diagnosis:

1. Ineffective Airway clearance. The inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
Tracheal bronchial inflammation, edema formation, increased sputum production Pleuritic pain Decreased energy, fatigue Changes in rate, depth of respirations Abnormal breath sounds, use of accessory muscles Dyspnea, cyanosis Cough, effective or ineffective; with/without sputum production

Goal: Outcomes:

The Patient will have Improved and Effective Airway Clearance. 1. Oxygen saturation at 93% without Nasal Canula or supplemental oxygen by discharge. 2. Chest x-ray clear of pneumonia by discharge.

Nursing Interventions
1. Elevate head of bed, change position frequently.
Rationale. Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions. http://nurseslabs.com/ineffective-airway-clearance-pneumonia-nursing-careplans/Taylor Fundamental Book 1385-1387

Evaluation (Clients Response) to the Nursing Interventions

2. Assist patient with frequent deep-breathing exercises.

Rationale. Deep breathing facilitates maximum expansion of the lungs/smaller airways. http://nurseslabs.com/ineffective-airway-clearance-pneumonia-nursing-careplans/Taylor Fundamental Book 1385-1387

3. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position.
Rationale: Providing assistance only as needed encourages independence in performing activities. http://nurseslabs.com/ineffective-airway-clearance-pneumonia-nursing-careplans/Taylor Fundamental Book 1385-1387

4. Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids.
Rationale. Fluids (especially warm liquids) aid in mobilization and expectoration of secretions. http://nurseslabs.com/ineffective-airway-clearance-pneumonia-nursing-careplans/Taylor Fundamental Book 1385-1387

5. Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy, e.g., incentive spirometer, IPPB, percussion, postural drainage.
Rationale. Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing, expectorations. Read more at Nurseslabs.com Ineffective Airway Clearance Pneumonia Nursing http://nurseslabs.com/ineffective-airway-clearance-pneumonia-nursing-careplans/Taylor Fundamental Book 1385-1387

Impression

Concept Mapping Page2 Nursing Diagnosis:

1. Impaired Physical mobility. A limitation in independent, purposeful physical movement of the body of one or more extremities. Bed rest up with assistance. Vertigo, dizziness, confusion,weakness.

Goal: Outcomes:

The Patient will have Improved physical mobility 1. The patient will sit in a chair twice a day for 30 minutes by discharge date. 2. The patient will ambulate to the end of the hall and back with assistance by discharge.

Nursing Interventions
1. The nurse will assist patient to chair twice a day for 30 minutes each time.
Rationale: Gradual activity progression prevents a sudden increase in cardiac workload. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

Evaluation (Clients Response) to the Nursing Interventions

1. The patient successfully sat in the chair by his bed for 30 minutes two times daily.

2. The nurse will assist to ambulate patient to the end of the 2. The patient successfully ambulated to the end of the hall and hall and back once a day. back to the room with nurses help and aid of walker.
Rationale: Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

3.

Nurse will assist patient to bathroom when needed.

Rationale: Providing assistance only as needed encourages independence in performing activities. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

3. Patient successfully ambulated to the bathroom with the assistance of the nurse andfamily.

4. Nurse will assist patient with Range of Motion exercises one time a day.
Rationale: Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse. http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

4. Patient successfully completed Range of Motion exercises with the assistance and guidance of the Nurse.

5. Nurse will monitor vital signs after exertion for base line differences.
Rationale: The stated parameters are helpful in assessing physiologic responses to the stress of activity http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_23.html

5. Patient's vital signs were successfully monitored by the Nurse before and after physical mobility and exertion.

Impression
The goals set for this patient were successfully met with the patient showing signs of Improved Physical Mobility.