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care plan mr r - Mr R PROBLEM"stroke NSG DX PLAN NURSING...

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Mr. R PROBLEM NSG DX PLAN NURSING ORDERS “stroke” P: risk for impaired tissue integrity E: related to bed rest / decreased mobility / dehydration / nutritional status / age EO: the pt will maintain intact skin 1. pt will turn every two hours 2. pt will maintain clean dry skin Dehydration P: Fluid volume deficient E: related to no po intake x2 days Underweight P: imbalanced nutrition less than body requirements E: unknown Limited movement P: impaired bed mobility E: related to brain attack ? living arrangement Priority – hydration 1. establish priorities a. various guides i. maslows hierarchy b. pt preference c. anticipate likely problems / complications d. what needs immediate attention? i. Skin breakdown ii. hydrations e. which problems can be referred? f. Which can use standard plans? g. Which problems are unique? i. Living situation 2. identify expected pt outcomes a. oriented toward i. health restoration ii. health maintenance iii. health promotion
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b. anticipated patient responses c. specific statements of pt behavior
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