Nursing Care Plan 1-Rotation 1 - Alice Ngo Care Plan 1 Demographics ClientsInitials:F.L.Age88y/oSex:FCodestatus:DNR Dateofadmission : All

Nursing Care Plan 1-Rotation 1 - Alice Ngo Care Plan 1...

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Alice Ngo 4/14/16 Care Plan 1 Nursing Care Plan 1- NANDA 1 Demographics: Client’s Initials: F. L.   Age 88 y/o   Sex: F    Code status: DNR Date of admission:  5/12/13 Recent surgery or procedures: Her last procedure was a urine culture during her last hospitalization  for a urinary tract infection Allergies: penicillin & cephalosporins NANDA Nursing Diagnosis: Impaired physical mobility rt joint stiffness and decreased range of motion AEB 2 people assists  during ADLs and inability of to transfer without assistance  Patient assessment and medical history rt problem: Osteoarthritis  History of childhood polio that left her with physical weakness throughout her body prominently on  her left side Upon assessment, patient had weakness in lower extremities and impaired range of motion during  transferring to the toilet.  Morbidly obese Widowed Rates an all over throbbing pain all over body that never goes below a 4 on a scale of 0-10  Patient Goal: She will increase muscle strengthening activity involving her upper extremities and lower  extremities by 4/12/16 Evaluation: She did improve her ability to perform passive range of motion to her upper and lower  extremities by the end of 4/12/16  Nursing Interventions : Therapeutic : “Before activity, observe for and, if possible, treat pain with medication as ordered to  increase readiness and willingness to move,” (NANDA, 2011). She does have scheduled Norco 650  mg 2 tab PO daily for pain relief, lidocaine patch to her right shoulder and lower back, and fentanyl  patch 75 mcg to the left chest.  Diagnostic : “Review her care plan regarding physical therapy, strength training, gait training, and  development of a mobility plan,” (NANDA, 2011). She does have physical strength training ordered  by PT that was reviewed regarding range of motion exercises to be done every over day.
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