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Nursing Care Plan: Impaired Walking

A sample nursing care plan I have made for a patient inside the surgical ward. This sample Nursing Care Plan is meant to enhance the Knowledge of a person interested in the field of Nursing.

Assessment

Subjective cues;

Client verbalized, “I Can’t walk my leg hurts.”

Objective cues;

-Incision site at both feet.

- Wound dressing on both feet

-Bi pedal swelling

Nursing Diagnosis

 Impaired walking R/T Musculoskeletal impairment as evidenced by bi pedal injury.

Definition:

Limitation of independent movement within the environment on foot.

Source:

Nurse’s Pocket Guide:Diagnoses, Prioritized, Interventions and rationale, 9th edition  

Rationale

Predisposing              Precipitating

-Age                    -Lack of    Family support      

                           -Poor wound hygiene

                           – Above normal

                              result in RBS

                          - Wound dressing

                             on both feet.

   ↘                                 

           Bus accident

                       ↓

Skin and tissue injury on both feet

                       ↓

Damaged veins, capillaries, nerve endings and muscles (digitorum brevis andhallucis longus).

                        ↓

Injury to metatarsal bones

                         ↓

Fracture of the phalanges

                         ↓

Impaired blood circulation

                          ↓

Disarticulation of the left big toe anddebridement of necrotic tissues

                         ↓

     Poor wound healing

                           ↓

             Impaired walking

Desired Outcome/objectives

Within 4 days of nursing intervention client will be able to:

1.      Identify precipitating factors & verbalize understanding about these precipitating factors

2.      Demonstrate activities of daily living that can be performed independently even on b ed.

  3.      Verbalize feelings regarding her health status.
Nursing intervention

INDEPENDENT

*Enumerate to the client the different precipitating factors and explain the importance of understanding these factors.

*Encourage patient to do some activities of daily living (bed such as tooth brushing, combing of hair, folding of blanket, and changing of clothes)

*Determine ability of the patient to follow directions when giving instructions and note emotional responses that may be affecting the situation.

*Provide ample time for the client to perform mobility related tasks.

COLLABORATIVE

1.Administered medication as prescribed

2. Refer to resources, as indicated such as physical therapy and occupational therapy

Source:

Nurse’s Pocket Guide:Diagnoses, Prioritized, Interventions and rationale, 9th edition

Justification

*To provide the client information about her health status. Identify conditions that may interfere with client’s recovery

* Promote mobility and independence in the part of the client.

*To assess the contributing factors to the clients health status.

*To help the client perform activities adequately and reduce the risk of falling and managing pain.

*To help the client recover

   *For further treatment of the illness.
Evaluation
After 4 days of nursing intervention client was able  to:
Evaluate your client basing on your desired outcome 

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