What could be the problem(s)?

Pain
The patient has a medical history of osteoarthritis and received medication for joint pain (8/10)
indicating that the patient is experiencing a moderate level of discomfort
Progressive decline in function
The patient is an 87 year old female who has been living in an extended care facility for three and a
half years after a progressive decline in function. A decline in function may indicate a progressive
increased need for assistance with activities of daily living
Voluntary decreased level of activity
Three weeks ago the patient asked for diapers and began to stay in bed
Impaired skin integrity
The patient has persistent erythema to the sacral area indicating the development of a stage one
pressure ulcer
Voluntary decreased social interaction
The patient tells the nurse that she does not want any interruptions and wants to rest indicating the
desire to withdraw from interactions with others
Risk for nutritional deficit, constipation, and dehydration
Due to the patients decreased mobility, she may experience decreased appetite and intestinal
peristalsis which may lead to the development of nutritional deficit, dehydration, and constipation
Risk for falls
The patient has experienced a progressive decline in function and has been in a wheelchair for 2 years
indicating that her ability to transport herself safely is impaired putting her at risk for falls
NANDA

Chronic pain R/T chronic physical disability AEB patient reports joint pain as 8/10
Sedentary lifestyle R/T lack of motivation AEB patients preference to stay in bed and watch
television
Impaired skin integrity R/T physical immobility AEB persistent erythema in sacral area
Risk for falls R/T wheelchair use and antihypertensive medication regimen
What would you assess?

Vital signs
Assess vital signs at regular intervals to note any changes in homeostasis
Pain
Assess pain level using the numerical (0 to 10) scale
Skin
Assess the skin for temperature, moisture, and changes in integrity
Lungs
Assess lung sounds for signs of secretion build up due to immobility
Gastrointestinal
1

Assess nutritional intake (24-hour recall) to determine risk for nutritional deficit and monitor
intake and output to assess for constipation
Urinary
Monitor intake and output to assess for dehydration
Musculoskeletal
Assess range of motion in mobile joints and strength in muscle groups to form a baseline
What should you do?

Administer pain medications as ordered in order to relieve pain

Help patient adjust in bed as much as possible and develop repositioning schedule to prevent
skin breakdown
Keep skin clean and dry to prevent breakdown
Teach patient to take deep breaths and cough at regular intervals to prevent secretion build-up
in the lungs
Determine the patients favorite foods and request a dietary consult for appropriate nutritional
intake
Request a physical therapy consult to develop individualized exercise program to maintain
muscle tone
Request occupational therapy consult to increase the number of activities of daily living
performed by the patient
Request psychological consult to assess for signs of depression
Provide the patient with entertainment by playing music or reading a book to improve mood
Encourage the patient to participate in social activities that are provided by the facility
Encourage the patient to go outside for a change in environment
Contact family members and encourage them to visit

Plan of Care
Nursing Diagnosis (Nanda r/t): sedentary lifestyle related to lack of interest
As evidenced by (Supporting Data Patient/Family, Vitals, Labs / Results, Assessment):
Subjective: patients request for diapers and desire to stay in bed
Objective: self-imposed immobility
Short Term Goal: Client will show increased level of physical activity in 24 hours as evidenced
by transferring to wheelchair for at least an hour
Long Term Goal: Client will achieve increased level of social activity in two weeks as
evidenced by participation in facility bingo game

Nursing Interventions
Administer pain medication as ordered
Teach and encourage use of relaxation
techniques such as focused breathing
and imaging
Assist patient with repositioning every
2 hours
Keep skin clean and dry
Encourage patient to sit in wheelchair
for short periods

Scientific Principle / Rationale

Decrease clients pain severity and
increase patients inclination for
activity
To distract attention from pain and
reduce tension
To prevent prolonged points of
pressure and/or decreased perfusion
To prevent maceration

Evaluation
Numerical pain scale and
level of physical activity
Numerical pain scale and
level of physical activity
Changes in skin integrity
Changes in skin integrity