NURSING PROCESS DOCUMENTATION Clients Initials: FH ASSESSMENT Data Collection (Identify Variable) PHYSIOLOGICAL

Objective:

Current Medical Diagnosis: DVT ANALYSIS Nursing Diagnosis Ineffective tissue perfusion (peripheral) R/T partial or complete venous obstruction a/e/b edema, pain, & ultrasound results. PLANNING Patient Outcomes Short term The client will agree to engage in activities to enhance tissue perfusion by 1000 on 6/14/11 Long term The client will participate in all behaviors, actions & exercises to enhance tissue perfusion on 6/14/11

Students IMPLEMENTATION Nursing Preventions (Identify Modality) Assess (Independent secondary)

The nurse will: 1. Monitor vital signs, palpate peripheral pulses routinely, evaluate capillary refill, changes in LOC, and note I&O 24-hour. Q 2 hrs. or as needed on 6/14/2011

EVALUATION Scientific Rationale

1. Indicators of circulatory adequacy.

Outcome Based Observation & Conclusions STG:

place -BP 157/75 -H/O of HTN, DM, and MI X4 -Resent cerebral accident left client with right sided weakness, decreased, decreased ROM, gait mobility, and confusion -Activity orders: PT 5X a week for 4 weeks ST 5X a week for 4 weeks. -Grip strength 1+ on R side, L side 5+ -edema 2+ right hand -reluctant to move right side as much as left -moves right side very slowly -swallowing also effected and client is on a pureed, thickened, & LCS diet -client used to be able to ambulate with a walker prior

Care/Perform/Provide (dependent secondary) The nurse will develop a mobility plan to share with client on 3/24/2011 The nurse will implement mobility exercises with the client daily. Teach/Educate/Supervise: (interdependent secondary) The nurse will collaborate with the Physical therapist before implementing activities for evaluation of mobility plan, strength training ideas, & gait training limitations before instructing &demonstrating exercises to the client on 3/24/2011. (e.g. active ROM on left side/ passive ROM on right side, leg/arm resistance, transferring goals, assistive devices and walking goals)

LTG:

PLAN:

to CVA now requires WC and assistance with ADLs Subjective: I cant walk like use to be able to. My right side is weaker than my left. reports mild pain when stretching out right hand PSYCHOLOGICAL Objective: -A&O X2 to person and place Subjective: -States He just doesnt know how hes going to get better. DEVELOPMENTAL Objective: 74y/o -High school education -Speaks English SOCIOCULTURAL: Objective: Divorced -Has 8 children -Lives with his daughter in a 2 story house(but stays on first floor) SPIRITUAL: Subjective: No preference

Manage/Refer/Contact: (independent secondary) The nurse will inform the

Physical therapist if the client is noncompliant & on general progress.