Let us take an example of rheumatoid arthritis
The common problems/needs are
- pain
- inability to walk
- inability to meet their needs
- feels bad/disturbed about the body imaGE
- difficulty in adhering to the treatment regimen
The possible nursing diagnosis are
- acute pain
- impaired physical mobility
- self care deficit
- disturbed body image
- non compliance
- anxiety
- knowledge deficit
- risk for comnplications
1. Acute pain
Assessment
subjective data:
patient may complain of pain;
Objective data:
look for dullness, sad face, irritable look/talk, pain
score:---/10
Goal: patient's
level of pain is minimised
Nursing Interventions
with rationale:
- Assess the level of pain - to plan the care
- position the patient comfortably - to promote comfort
- provide comfort device- to reduce the direct pressure
- provide divertional therapy in varioous forms like music,
reading /listening to news - to divert the mind from thinking about
pain
- apply hot / cold applications as per order if there are no
contra indications - to reduce joint stiffness
- advice/ allow a close relative to be with the patient - to
divert from thinking about pain
- administer analgesics as per order - to reduce the pain
Evaluation
- The patient's pain level has reduced from ---- to -----
2. Impaired physical mobility
Assessment
- Subj. data - patient may complain of inability to walk
- obj.data - patient's level of activity is restricted; inability
to carry out daily activities, inability to perform gross / fine
motor activities
Nursing diagnosis - Impaired physical mobility
Goal - patient's level of mobility is improved
Nursing Interventions
- Assess the level of mobility - bed mobility, supported and
unsupported sitting , transition movements like turning etc - to
plan the care
- monitor and record client's abiolity to tolerate activity - to
provide activity
- observe for and treat pain before activity - to enhance the
activity level
- perform passive ROM or teach active ROM as per need - to
improve the activity level
- offer any assistive devices as per need - to help in
mobility
- use a walking belt if needed when ambulating - to prevent
injury
- set achievable goals - to enhance sense of participation
- gradually improve the levelof activity - to improve
tolerance
3.