The range of Motion and strength in hips normal completes the whole arc of movements against gravity and resistance without s/s difficulty. ROM and Knee bend normally against gravity, resistance testing deferred due to edema, erythema and popliteal wound. Unable to complete the whole arc of ankle rotation due to pain with movement and edema. Pedal push-pull motion intact, push against full resistance to bottom of foot done without difficulty, equal strength bilaterally. Flexion of foot resistance deferred due to the presence of edema and erythema. Transferred from sitting to standing independently, no help or staff oversight needed. Patient ambulates ad lib without difficulty, gait even and steady. Negative Romberg test. The curvature of spine normal with double-S
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Nurse will establish a therapeutic relationship with patient to promote insight and positive behavioral changes.
b. Nurse will perform a psychosocial assessment to determine effects of prior experiences and coping skills used, including smoking and alcohol use.
c. Nurse will use therapeutic communication to explain disease process, contributing factors, benefits of life style and dietary modifications to promote patient participation and collaboration in plan of care.
d. Nurse will promote self-responsibility by encouraging patient to assume more responsibility for own behavior and self-care.
e. Nurse will provide medication education, including indication, benefits and side effects, to facilitate medication safety and promote self-care of patient.
3. Evaluation; not-met, Unable to verbalize appropriate indication of use for home medication (prednisone). The actual problem is still present, expected outcomes not meet due to lack of implementation. This goal is realistic and achievable, recommend continuation of current nursing interventions.
(Wilkinson, 2017., p. 390-393)
C. Risk for infection related to loss of skin integrity and smoking, AEB open wound, edema and erythema of lower
Nurse will establish a therapeutic relationship with patient to promote insight and positive behavioral changes.
b. Nurse will perform a psychosocial assessment to determine effects of prior experiences and coping skills used, including smoking and alcohol use.
c. Nurse will use therapeutic communication to explain disease process, contributing factors, benefits of life style and dietary modifications to promote patient participation and collaboration in plan of care.
d. Nurse will promote self-responsibility by encouraging patient to assume more responsibility for own behavior and self-care.
e. Nurse will provide medication education, including indication, benefits and side effects, to facilitate medication safety and promote self-care of patient.
3. Evaluation; not-met, Unable to verbalize appropriate indication of use for home medication (prednisone). The actual problem is still present, expected outcomes not meet due to lack of implementation. This goal is realistic and achievable, recommend continuation of current nursing interventions.
(Wilkinson, 2017., p. 390-393)
C. Risk for infection related to loss of skin integrity and smoking, AEB open wound, edema and erythema of lower