Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

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 

Problem

Impaired physical mobility 
 
 

Long Term:

Client will be able to perform ROM exercises three times per day.

Nurse will have resident perform active range of motion exercises twice during shift.

Nurse will encourage patient throughout ROM sessions.

 Resident performed ROM exercises one time during shift.

 Physical Therapist worked with ME to perform ROM exercises.

R/T 

Acute pain 

Obesity

Short Term:

Client will maintain a positive attitude about physical condition when working with nurse.

Nurse will encourage patient throughout ROM sessions.

 Physical Therapist worked with ME to perform ROM exercises.

 Nurse encourage ROM activities twice on shift.

AEB 

Client’s inability to walk.