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Level 2 Assessment

Planning/Interventions

Activity and Rest

- inadequate sleep for past 3 nights (I)

- slow and unsteady gait (I)

- able to perform simple ADLs such as brushing hair (A)

- very shaky when moving from a lying position to a sitting position (I)

Focal: difficulty tolerating physical activity

Contextual: pain

Residual: loss of motivation

- health teaching

- encourage pt to stand up and walk around his room

- manage pain (assess pain every hour)

- encourage food intake for energy

- preform ROM on pt

Level 1 Assessment

(Physiological Mode)

Evaluation

Nursing Diagnosis

NANDA statement

Oxygenation

- O2 sat: 96% room air (A)

- symmetrical lung expansion (A)

Elimination

- <50mL in 3hrs (I)

- no bowel movement (I)

- hematuria (I)

- on a CBI and drainage was serous-sang; almost clear (A)

Nutrition

- ate less than half his breakfast (I)

- drinking plenty of water (A)

- mucous membrane moist (A)

Activity and Rest

- inadequate sleep for past 3 nights (I)

- slow and unsteady gait (I)

- able to perform simple ADLs such as brushing hair (A)

- very shaky when moving from a lying position to a sitting position (I)

Senses

- pain 9/10 (I)

- reoccurring bladder spasms (I)

- Constant right flank pain (I)

Protection

- bruising and redness around coccyx (I)

Activity intolerance r/t inadequate motivation secondary to pain

- Pt will show knowledge of health teaching as evidenced by answering questions adequately on the importance of physical activity

- Pt will show improvement of physical activity as evidenced by walking around the room for >5min

- Pt will show improvement by pain as evidenced by a self-report of pain that is <5/10

- Pt will show improvement of food intake as evidenced by a consumption of >3/4 of meal

- Pt will show an increased motivation in activity tolerance as evidenced by active participation in ROM sessions

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PRIORITY

Reflects nursing interventions

Client Health Profile

Name: Mr. P.

Age: 60

Gender: M

Admitting Diagnosis: Atrial fibrillation

Health History: Radical prostatectomy, diabetes, hypertension, sleep apnea

Level of Risk for Falls: Moderate

Care providers: doctor, nurse, pain management nurse

Rovustatin

Pantoprazole

Medication:

Tylenol #3

Opium-Belladonna

Metoprolol

Nursing Care Plan Presentation

By: Charlene Raymundo BScN 2

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