Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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Subjective
Pt seems very happy with state of health but has a 46
lbs to lose seeing as her idea weight is 150lbs.
Trouble lifting arms above shoulder and left leg gives pain level of 6 during
ROM exercises.
Objective
History of Chronic Obstructive Pulmonary Disease, receives
oxygen therapy 2mL/min, morbidly obese, severe immobilization, patient in wheel
chair all day
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Problem
Impaired physical mobility
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Long Term:
Client will be able to perform ROM exercises three times
per day.
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Nurse will have resident perform active range of motion
exercises twice during shift.
Nurse will encourage patient throughout ROM sessions.
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Resident performed ROM exercises one time during
shift.
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Physical Therapist worked with ME to perform ROM
exercises.
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R/T
Acute pain
Obesity
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Short Term:
Client will maintain a positive attitude about physical
condition when working with nurse.
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Nurse will encourage patient throughout ROM sessions.
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Physical Therapist worked with ME to perform ROM
exercises.
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Nurse encourage
ROM activities twice on shift.
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