Nursing Process Assessment Paper

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Nursing Process Phases Assessment Diagnosis Planning Outcomes Planning and Implementation of Interventions Evaluation Nursing Care Plan Headings Data Nursing Diagnosis Outcomes/Goals Interventions Rationale Evaluation Impaired Physical mobility Objective: Inability to ambulate or complete transfers independently, dependence on ceiling lift and wheelchair, limited ROM in LE, and decreased strength in LE and UE. Subjective: Postoperative pain, and severe to moderate pain in the left clavicle, pelvis, and right femur.

Impaired physical mobility RT polytrauma due to a MVA and recent ORIF on the left clavicle, and left acetabulum, and right femur IMN AEB inability to ambulate or complete transfers independently, dependence on ceiling lift and …show more content…
A: Given the patient's current condition and motivation, achieving this short-term goal is realistic. R: Addressing immediate mobility and pain management issues will enhance the patient's overall recovery and rehabilitation process. T: Set to be completed within the next two weeks to facilitate early progress and enhance the patient's comfort and mobility during the initial phase of recovery as well as minimize the risk of DVT …show more content…
Schedule appointments with an OT that can assist with creating a personalized physical therapy program focused on lower extremity strengthening exercises and transfer techniques. Encourage patient to perform physiotherapy exercises that can be performed independently.

Schedule a collaborative care meeting between the PT, OT, primary physician and nursing team to discuss the patient's progress and pain management reassessment.

Implementing pain management strategies prior to transfers ensures the patient experiences reduced discomfort during movements, facilitating smoother transitions and minimizing the risk of complications associated with immobility. Additionally, effective pain management promotes adherence to the treatment plan, as patients are more likely to comply with therapy sessions and medication schedules when their discomfort is adequately addressed (Tsegaye, 2023).

A targeted approach that maximizes mobility improvement and functional independence, empowers the patient with essential skills for ongoing recovery and reduces the risk of future injuries. Not to mention a structured program that allows for goal attainment to be measured and quantifies the patient’s
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