alteration of physical mobility;

self-care deficit;
urinary Incontinence
risk of impaired skin integrity;
risk of impaired nutrition;
inability to communicate;
alteration of self-image;
Inadequate circulation;
risk of social worthlessness syndrome.
alteration of nutrition
The patient shows a deficient breathing
My goals are for Jane to present
- permeable respiratory tract and good breathing
- to have a regular respiratory rhythm.
- Interventions
monitoring of vital signs
ade quvate positions that favor respiration (change position 2 in 2h)
I educate the patient how to perform breathing exercises
administration of medication prescribed by the doctor
Alteration of mobility by :
Multiple infarcts in the right occipital and right cerebellar mid-brain
Left basilar artery thrombosis
Left vertebral artery dissection all resulting from RTA
Tracheostomy and peg feeding in situ
Jane shows difficulty in getting up, going
bed rest, limited degree of movement
to regain strength and muscle tone
mobilize passively the patient 2 in 2h
Massage the regions prone to bedsores
I help the patient in meeting his needs
I serve her in bed with the necessary things
provide the conditions needed for bed rest
Inappropriate nutrition due to tracheostomy and peg feeding in situ.
Jane to be balanced physically, not to present digestive syndrome


-to get food that correspond in terms of quality and quantity
fluid resuscitation
provide comfort in order to allow a correct feed process
I prepare the tray for leakage
I peg feed Jane with Fresubin energy alternating with Fresubin energy fibre at 55mls per hour over 20 hours and Flush with 100mls water
6 times daily plus 100mls pre and post feed .

I measure her weight

Jane shows degradation of autonomy for personal care due to the immobilization
to maintain skin integrity

to avoid the risk of developing pressure sores
to assure the materials for making the hygiene at bed

assure clean body and bed sheets
assure microenvironment in the salon and bed rest
assure hygienic-dietary regime and adequate hydration for her
Patient I explain to her the possible consequences of the immobilization and preventive measures taken

I change her position from 2 to 2h.

Jane is totally immobile and requires hoist for transfer. She has her own wheelchair that she sits in upstairs during the day. Please note that
Jane is unable to maintain independent sitting balance at 90degrees so chair must always be tilted back.
Jane also requires max assistance with bed mobility
I help her in making the transfer from her bed into the wheelchair when she wants to sit upstairs during the day.

Jane shows inability to rest due to anxiety
satisfy her need for sleep
I create a climate of confidence by encouraging her and favoring rest by playing her favorite music
I teach her how to perform relaxation techniques
I teach her family how to communicate with her in order to reduce anxiety
I observe and communicate to the doctor the changes that appear in her behavior
Jane shows disequilibrium in urinary elimination due to mobilization in bed
keeping them clean and dry the skin
My goal for Jane are to keep her skin dry and clean
I continuously monitor the quantity / quality emission of urine and feces
I change her diaper whenever it is necessary.
I give her a full body wash at least once daily and Igive her regular mouth care throughout the day.