Goals Plan Rationale Implementation Evaluation

NM 222 Clinical Nursing I Name

Herzing University BSN Program Care Plan Assignment
Assessment Nursing Diagnoses Outcome / Goals Plan Rationale Implementation Evaluation
Pt. stated she has Numbness or tingling of hands and feet. Pt. stated she has Blurred vision,Headaches, andNightmares.Objective:Pt. skin wasWarm and Dry, Sugar High.240 mg/dLV.S. T-99.8,R-20,P-97, BP- 110/68 O2- 92

NM 222 Clinical Nursing I Name: Bindu Komara

Herzing University BSN Program Care Plan Assignment
Assessment Nursing Diagnoses Outcome / Goals Plan Rationale Implementation Evaluation
Subjective Data:Pt. stated that she has pain in her legs 8/10Pt. stated having stiffness in bilateral legsObjective Data:Tenderness and redness to bilateral legs joints.Joint area is warm to touchVS:BP-144/70,R-20,P-57, T-97.6,02-96% RA Acute pain related to inflammation as evidence by pain of 8/10 tenderness, swelling and warmth.Impaired physical mobility related presence of joint pain.Potential for impaired skin integrity related to inflammation to bilateral legs as evidence by redness, tenderness, and warm. Reduce inflammation result to reduction in pain to 2/10 or at a tolerable levelPt. will be able to have full ROM to bilateral lower extremities (BLE) without complaint of pain.Patient will have reduce inflammation to BLE to reduce risk of skin integrity