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NURSING PROCESS DOCUMENTATION

Clients Initials: FH Current Medical Diagnosis: DVT Students

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

Data Collection

(IdentifyVariable)

Nursing

Diagnosis

Patient

Outcomes

Nursing Preventions

(Identify Modality)

Scientific

Rationale

Outcome Based

Observation &ConclusionsPHYSIOLOGICAL Objective:place-BP 157/75-H/O of HTN, DM,and MI X4-Resent cerebralaccident left clientwith right sidedweakness,

decreased,decreased ROM,gait mobility, andconfusion-Activity orders: PT5X a week for 4weeksST 5X a week for 4weeks.-Grip strength 1+on R side, L side 5+-edema 2+ right

hand-reluctant to moveright side as muchas left-moves right sidevery slowly-swallowing alsoeffected and clientis on a pureed,thickened, & LCSdiet-client used to be

able to ambulatewith a walker prior

Ineffective tissueperfusion(peripheral) R/Tpartial or completevenous obstructiona/e/b edema, pain,& ultrasoundresults.

Short termThe client will agreeto engage inactivities to enhancetissue perfusion by1000 on 6/14/11

Long termThe client willparticipate in all

behaviors, actions &exercises toenhance tissueperfusion on 6/14/11

Assess(Independent secondary)The nurse will:

1. Monitor vital signs, palpateperipheral pulses routinely,evaluate capillary refill,changes in LOC, and noteI&O 24-hour. Q 2 hrs. or asneeded on 6/14/2011

Care/Perform/Provide(dependent secondary)The nurse will develop amobility plan to share withclient on 3/24/2011The nurse will implementmobility exercises with theclient daily.

Teach/Educate/Supervise:(interdependent secondary)The nurse will collaborate with

the Physical therapist beforeimplementing activities forevaluation of mobility plan,strength training ideas, & gaittraining limitations beforeinstructing &demonstratingexercises to the client on3/24/2011.(e.g. active ROM on left side/passive ROM on right side,leg/arm resistance, transferringgoals, assistive devices andwalking goals)

1. Indicators of circulatoryadequacy.

STG:

LTG:

PLAN:

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to CVA now requiresWC and assistancewith ADLsSubjective:I cant walk likeuse to be able to.My right side isweaker than my

left. reports mild painwhen stretching outright handPSYCHOLOGICALObjective:-A&O X2 to personand placeSubjective:-States He justdoesnt know howhes going to get

better.DEVELOPMENTALObjective: 74y/o-High schooleducation-Speaks EnglishSOCIOCULTURAL:Objective: Divorced-Has 8 children-Lives with hisdaughter in a 2story house(but

stays on first floor)SPIRITUAL:Subjective:No preference

Manage/Refer/Contact:(independent secondary)

The nurse will inform thePhysical therapist if theclient is noncompliant & ongeneral progress.

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