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This nursing care plan summarizes the care for a 72-year-old patient post lumbar fusion surgery. The patient has 3 nursing diagnoses: 1) Impaired physical mobility due to pain, weakness, and medications; 2) Risk for impaired skin integrity due to immobility and catheter use; and 3) Self-care deficit due to the surgical procedure and medications. Interventions include assisting with exercises, ADLs, and hygiene, repositioning every 2 hours to prevent pressure ulcers, and teaching the importance of mobility and skin care. Goals are to participate in PT, be free of pressure ulcers, and assist with self-care. Findings after interventions will be documented.

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SACHA DE MENDONCA ZAPORSKI
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7 views

Concept Map Print

This nursing care plan summarizes the care for a 72-year-old patient post lumbar fusion surgery. The patient has 3 nursing diagnoses: 1) Impaired physical mobility due to pain, weakness, and medications; 2) Risk for impaired skin integrity due to immobility and catheter use; and 3) Self-care deficit due to the surgical procedure and medications. Interventions include assisting with exercises, ADLs, and hygiene, repositioning every 2 hours to prevent pressure ulcers, and teaching the importance of mobility and skin care. Goals are to participate in PT, be free of pressure ulcers, and assist with self-care. Findings after interventions will be documented.

Uploaded by

SACHA DE MENDONCA ZAPORSKI
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CNUR 205/206 Care Planning Template Student Name: Sacha Zaporski

***Prioritize your ND***

# ____ Nursing Diagnosis Client Room # 21-2 Age: 72 y/0

Impaired Physical Mobility r/t pain Allergies: Codeine Code Status: CPR

- Total lift
- Generalized weakness Admitting Dx: Spondylolisthesis and Stenosis
- Pain rated 3/10 on surgical site
- Osteoarthritis of knee Surgical Procedure: Stereotactic L2-L5 posterior decompression &
- Hydromorphone 3mg SR BID instrumented infusion with transforaminal lumbar interbody fusion at
- Citalopram 20mg can cause L2/L3, L3/L4, L4/L5
weakness and drowsiness as side
effect
POD # 9 days
- Gabapentin 100mg TID can cause
dizziness and drowsiness as side
effect.

# ____ Nursing Diagnosis # ____ Nursing Diagnosis

Risk for Impaired Skin Integrity r/t immobility Self-care deficit r/t surgical procedure

- Braden Scale 16 - Assisted ADL’s


- Total Lift - Foley catheter
- Foley catheter - Assisted personal hygiene
- Pain with movement - Generalized weakness
- Citalopram 20mg can cause weakness and
drowsiness as side effect
- Gabapentin 100mg TID can cause dizziness and
drowsiness as side effect.

#____ Nursing Diagnosis Nursing Interventions & Rationales ( select major interventions) Findings/What were my findings after I performed my
What am I going to do? intervention?
Evaluation/Reassess
Impaired physical mobility What am I going to teach? Did I meet my goal? If not, why?
Were my interventions appropriate?
Is this Nursing Diagnosis still appropriate?

Assess
Goals (SMART) 1. Assess ability to perform ROM to upper and lower extremities

Patient will participate in 2. Assess pain assessment prior PT session.


exercises during PT session as
much as possible. Do
1. Assist with ADL’s as needed
2. Provide positive reinforcement while patient in doing PT session

Teach
(Circle one) 1. Reinforce the importance of daily exercise
Met/Partially Met/Unmet 2. Explain the importance of making the home environment safe and easy to navigate
without any cluster or items on the floor.

#____ Nursing Diagnosis Nursing Interventions & Rationales ( select major interventions) Findings/What were my findings after I performed my
What am I going to do? intervention?
Evaluation/Reassess
R/f impaired skin integrity What am I going to teach? Did I meet my goal? If not, why?
Were my interventions appropriate?
Is this Nursing Diagnosis still appropriate?

Assess
Goals (SMART) 1. Assess skin for pressure ulcer
2. Assess Braden Scale qshift
Patient will be free of pressure
ulcer within clinical shift.
Do
1. Reposition patient q2hr
2. Protect pressure points by using pillows
(Circle one)
Met/Partially Met/Unmet Teach

1. Teach patient the importance of frequently reposition


2. Teach patient the importance of keeping skin moisturised to prevent skin breakdown
#____ Nursing Diagnosis Nursing Interventions & Rationales ( select major interventions) Findings/What were my findings after I performed my
What am I going to do? intervention?
Evaluation/Reassess
What am I going to teach? Did I meet my goal? If not, why?
Self-care deficit Were my interventions appropriate?
Is this Nursing Diagnosis still appropriate?

Assess
Goals (SMART) 1. Assess patient ability to perform ADL in the morning
2. Assess patient upper and lower extremities strengths prior self-care
Patient will be able to assist in
Self-care as much as possible
within clinical shift Do
1. Assist patient will self-care routines
2. Provide positive reinforcement while assisting patient in activity;

(Circle one) Teach


Met/Partially Met/Unmet 1. Teach patient importance of using assistive device;
2. Be available for discussions of feelings about situations

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