NUR5ING NURSING

PROBLEMS with DIAGNOSIS GOALS/ NURSING RATIONALE EXPECTED EVALUATION

CUES with OBJECTIVES INTERVENTION OUTCOMES
RATIONALE S
Bedridden Impaired physical Short term: 1. Assess - identifies strength or
mobility related to After 8 hours of functional ability. deficiencies & may
Subjective: impaired skin nursing provide information
“Not applicable” integrity. intervention, regarding recovery &
patient will assists in choice of
Objective: Rationale: increase muscle interventions.
- powerlessness Immobility refers strength & can
- fatigue to a reduction or perform body 2. Regular turning
- discomfort in the amount & movements such 2. Turn & position promotes circulation
- prolonged bed rest control of as raising her patient every two to all tissues &
- ↓ muscle strength movement a hands. hours. relieves pressure.
- limited body person has
movements normally people Long term: 3. Reduces risk for
- respiratory distress more when they After 2-3 days of 3. Provide good decreased perfusion
with R.R of 40 experience nursing skin care & gently & ischemia to prevent
- presence of pain discomfort due to intervention massage pressure skin
pressure on an patient points after each irritation/breakdown.
area of the body. position change.
4. Reduces muscle
(Fundamentals of 4. Encourage use of tension, fatigue &
nursing, Kozier’s: relaxation help limit pain of
p. 904). technique. muscle spasm.

5. Maintains mobility
& function of joints,
5. Perform active & functional alignment
passive ROM of extremities,
minimizes muscles
atrophy, promotes
circulation & reduces
venous stasis.
 6. Patient is at risk for
development of deep
vein thrombosis
(DVT) & can cause
6. Inspect for pulmonary embolism,
localized requiring prompt
tenderness, redness intervention to
& ropy veins in prevent serious
calves of legs. complications.

7. Apply anti- 7. Limits pooling of

embolic stockings. blood in lower
extremities &
reducing incidence of
thrombus formation
(DVT & pulmonary
emboli).

8. Administer 8.
medication for pain
as indicated such as
Tramadol.
 NUR5ING NURSING
PROBLEMS with DIAGNOSIS GOALS/ NURSING RATIONALE EXPECTED EVALUATION
CUES with OBJECTIVES INTERVENTION OUTCOMES
RATIONALE S
Constipation Constipation Short term: 1. Assess usual 1. Normal frequency Short term: Goal partially met:
related to After 3-5 hours of pattern of of passing stool varies After 3-5 hours
Subjective: decreased nursing elimination; from twice daily to of nursing After 3 days of nursing
“Not applicable” physical activity interventions, the compare with once every third or interventions, the interventions, the
or immobility. patient will present pattern. fourth day. It is patient will patient can demonstrate
Objective: defecate. Include size, important to ascertain demonstrate normally but because of
- not defecating Rationale: frequency, color, & what is normal for improved bowel using laxatives.
within 3 days In the patient Long term: quality. each individual. function.
- distended abdomen experiencing After 2-3 days of (Gulanick, p.43)
- constipated date: decreased nursing Long term:
10-20-09 physical activity intervention 2. Check for 2. Further After 2-3 days of
10-30-09 is risk to have patient will impaction if patient interventions/alternati nursing
11-03-09 constipation defecate normally has not had bowel ve bowel care may be intervention
because it can movement in 3 needed. (Doenges, p. patient will
alter the days or is 829). demonstrate
abdominal cavity abdominal normal defection
to function well & distortion, without using
to have decreased cramping. laxatives.
peristaltic
movement. 3. Digitally remove 3. Stool that remains
(Snell, p.122) fecal impaction. in the rectum for long
periods becomes dry
& hard; debilitated
patients, especially
elderly patients, may
not be able to pass
stools without manual
assistance. (Gulanick,
p. 44).
4. Offer a warmed 4. This position best
bedpan to uses gravity & allows
bedridden patients; for effective valsalva
assist patient to maneuver. (Gulanick,
assume a high- p.44)
fowler’s position
with knees flexed.

5. Provide rectal 5. Necessary to

tube, suppositories, relieve abdominal
& enemas as distension, promote
needed. resumption of normal
bowel habits.
(Doenges, p. 267).

6. Administer 6. Softens stools,

laxatives, stool promotes normal
softeners as habits/evacuation,
indicated (e.g. and decreases
lactulose). straining. (Doenges,
p. 267).