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Nursing Care Plan Concept Map

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Jakki Petrie

on 28 April 2014

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Transcript of Nursing Care Plan Concept Map

Long-term goal
Client will be able to bathe and dress self independently by time of discharge of St. Elizabeth's Hospital.

Short-term goal
Client will properly demonstrate methods to bathe and dress self with use of health care provider assistance by end of shift.

Nursing Care Plan Concept Map

Impaired Physical Mobility

Self- Care Deficit
Impaired Verbal Communication
Nursing Intervention #2
Implement the use of constraint-induced movement therapy (CIMT), where the functional right extremity is purposely constrained and the client is forced to use the involved left extremity.
Nursing Intervention #3
During meals, sit side-by-side with the client, put your hand over the client’s hand, support the client’s elbow with your other hand, and help the client feed self.
Nursing Intervention #1
Nursing Intervention #2
Adaptive devices increase self- care ability add can decrease self- care exertion (Swann, 2006). Adaptive clothing can make dressing easier for those with impaired mobility
(Swann, 2008).
Intervention #3
Facilitate with bathing process by adapting environment through obtaining items used for bed bath and by placing items within reach of client.
Long Term Goal:

Client will properly verbalize 100% of understanding of patient education by time of discharge from St. Elizabeth's Hospital.
Intervention #1
Use therapeutic communication techniques such as maintaining eye contact, using simple communication (pointing to necessary objects), and speaking in a loud, clear voice.
Nursing Intervention #2
Nonvocal and ventilated patients reported to appreciate persistence on the nurses' part with respect of being understood, as well as being reported annoyance when others pretended to understand them (Carrol, 2007).
Patient Summary
Age: 51
College-Bachelor Degree
Marathon Runner
Family Hx. of Heart Disease
No hx. of tobacco, alcohol, or drug use

Reason for Admission:
Left sided weakness
Current medical diagnosis: CVA (Stroke), Hypertension
General Appearance:
Generally well, slightly tired, clean and well groomed, expressions are
appropriate, expressive aphasia,
left sided weakness
Fall Risk: High
Code Status: Full
Vital Signs
98 F
Blood Pressure-
96% room air
Past History/Surgeries:
Pacemaker inserted 7 years ago
Pertinent Labs:
CT Scan 2/8/14-Occluded R internal carotid
CT Scan 2/10/14-CVA affected R middle cerebral artery
INR 3/10/14: PT 27.1 (high)
INR 2.58 (high)
Glucose 104 (high)

r/t left sided weakness
r/t left side musculoskeletal impairment and left side neuromuscular impairment

r/t decreased circulation to brain
AEB: difficulty expressing thoughts verbally
(expressive aphasia)
Long-term goal:
Client will demonstrate ability to feed himself with a spoon using the left hand by date of discharge.

AEB: impaired ability to wash body and put on necessary items of clothing on upper & lower body.
for 15 minutes within a month of discharge.
for a walk without an assistive device
Client will be able to go
Short Term goal:
Short Term Goal:
Client will demonstrate effective communication without feeling frustrated or helpless by the end of the current shift.
Increase independence in ADLs, encouraging self-efficacy and discouraging helplessness as the client gets stronger, placing emphasis on the client' use of left hand.

Teach the client relaxation techniques such as deep breathing and stretching to use during activity.
Reiterate what the client says to ensure proper understanding of the client. If the patient's message is unclear, avoid pretending comprehension.
Nursing intervention #1
The patient may feel anxiety or frustration during activity. Deep breathing has been shown to help the relaxation process.

Intervention #3
Encourage patient to effectively
communicate when additional assistance is needed.
Participation in self-care improves functioning,
self- esteem, and family and caregiver
satisfaction while reducing functional decline and disablity
(Resnik et al, 2008).
When forced to use a less functional extremity instead of relying on the stronger one, it forces the strengthening and functionality of the affected extremity.
(Wu et al, 2007)
Effective communication between clients and health care professionals facilitates positive relations
(Wain, Kneebone, & Billings, 2008).
(Harvard Medical School, 2006)
Instruct the patient and primary caregiver on how to correctly select and use adaptive clothing, such as elastic waistbands and cuffs, Velcro fasteners, magnetic buttons, and coats with zippers in the front.
Assisting the client with ADLs while still allowing them to go through the motion will slowly help them build strength.
(Resnick et al, 2009)
Carroll, S.M.: Silent, slow lifeworld: the communication experiences of nonvocal ventilated
patients, Qual Health Res 17(9):1165-1177, 2007.
Foster A., et al: Rehabilitation for older people in long-term care, Cochrane Database Syst
Rev(1):CD004294, 2011.
Harvard Medical School (2006, October). Relaxation techniques: Breath control helps quell
errant stress response. Retrieved April 16, 2014, from http://www.health.harvard.edu/fhg/updates/update1006a.shtml
Naik, A. & Gill, T.: Underutilization of environmental adaptations for bathing in
community-living older persons, J Am Geriatr Soc 53(9):1497-1503, 2005.
Resnick, B., et al: Barriers and benefits to implementing a restorative care intervention in
nursing homes, J Am Med Dir Assoc 9:102-108, 2008.
Resnick, B., et al: Nursing home resident outcomes from the Res-Care Intervention, J Am
Geriatr Soc 57(7):1156-1165, 2009.
Swann, J.: Managing dressing problems in older adults in long-term care, Nurs Resident
Care 10(11):564-567, 2008.
UC Davis Medical Center (2014). Speaking up for safest care. Retrieved April 16, 2014, from
Wain, H.R., Kneebone I.I., & Billings, J.: Patient experience of neurologic rehabilitation: a
qualitative investigation, Arch Phys Med Rehabil 63(5):527-534, 2008.
Wu C.Y., et al: A randomized controlled trial of modified constraint-induced movement
therapy for elderly stroke survivors: changes in motor impairment, daily functioning, and quality of life, Arch Phys Med Rehabil 88(3):273-278, 2007.
Encouraging patients to verbally share their questions is an extremely powerful safety measure and ranks among national safety initiatives created by The Joint Commission, the nation’s predominant health standards-setting body (UC Davis Medical Center, 2014).
Adapting environmental factors for bathing may help prevent bathing disability and attempt to promote appropriate amount of bathing independence
(Naik & Gill, 2005).
AEB: difficulty performing tasks with left side including walking and use of left arm.
Jenna Schultz
Jakki Petrie
Elise Eidson
Payton Swan

Nursing Interventi0n #4
Assist in performing range of motion exercises and increasing strength of left upper and left lower extremity at least twice a day.
Range of motion exercises allow for the passive and active movement of the extremity, resulting in higher endurance and flexibility. Physical rehabilitation interventions were found to be safe, reduced disability, and resulted in fewer adverse events.
(Foster et al, 2011)
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