Student Minnie Mouse Date of care 8/7/10 Resident Initials CPK

Resident Diagnosis or reason for admission Decreased mobility; stroke

FINDINGS OF CONCERN (DATA) Problem + supporting evidence & related Functional Health Pattern
1. Left sided weakness Identify the problems from the data but select the THREE (3) issues that
2. L handed
are the highest priority. Identify the FHP that is appropriate for the
3. Difficulty changing position by self
problem. List the data that supports each issue
4. Unable to stand by self
5. Wears brief
6. Unaware of need to go to bathroom 1. Unable to toilet self – Elimination 1, 4, 5, 6
7. Difficulty feeding self
2. Poor mobility – Activity and Exercise 1, 3, 4
3. Cannot feed self – Nutrition 1, 2

NURSING PRESCRIPTIONS (Interventions)what can you, the student do?

1a. Check brief Q 2 hrs & change prn

2a. OOB to chair w 1 person assist for breakfast

2b. In bed, turn R side to back to L side Q 2H
2c. 4” foam chair cushion when OOB
2d. AROM all but L side Q 4H WA
2e. PROM L arm & leg Q4H WA

Think about why your person is here? f. 3a. Set up tray

Why can they not take care of 3b 3b. Open containers & utensils
themselves? What is it that they cannot 3c 3c. Place towel over chest
do?