UNIVERSITY OF SOUTH CAROLINA UPSTATE
Client Room # __**13________
Client Initials _HIPPA___
Mary Black School of Nursing
Baccalaureate Nursing Program
PLAN OF CARE
Name _Kelby Tidey____
Date__
18 June 2012_____________
Course __Pediatrics_____________________
Long Term/Discharge Goal: Patient will be able to ambulate independently without discomfort or pain by the time of discharge.
Nursing Diagnosis
Subjective/Objective Data
NANDA
1. Impaired physical mobility
related to pain from surgery as
evidence by gait changes.
a. Sub: “I can’t walk
right because I’m
sour from surgery.”
b. Obj: patient has a
very short and slow
gate, and only leads
with the right foot
during ambulation.
Client Outcome
NOC

Patient will be able to
ambulate 200 feet with
assistance by post-op day 3
(06/18/2012).
Nursing Interventions
NIC



Assess patient’s level of pain
before ambulation and
administer prn
hydromorphone if needed.
Assist with ambulation to
avoid patient injury.
Cleared the patient’s
environment of any tripping
hazards.
RATIONALE



1.
Impaired comfort related
stomach pain as evidence by
disturbed sleep pattern.
a. Sub: “I couldn’t
sleep at all last night
because I had gas.
It’s gone now
though.”
b. Obj: patient looked
slightly groggy and

Patient’s level of comfort will
improve by end of shift ( At
1400 on 06/18/2012)



Cluster patient care to allow
for lengthy rest periods
between assessments and
interventions.
Decrease sensory input from
electronic devices in patient’s
room.
Collaborate with patient’s
health care team to allow for
an adequate throughout the
1



Assessment of patient’s pain
will determine if analgesics
are needed for ambulation. If
patient’s pain level isn’t
assessed properly this can
result in unproductive
ambulation.
Assisting with patient
ambulation ensures safety of
the patient and others in their
surrounding area. This also
provides support and
motivation because the patient
is helped and not forced to
ambulate by their self.
Clearing the patient’s
environment eliminates any
hazards that would cause any
injury during ambulation due
to tripping, therefore any
injury would be caused by
patient’s inability to talk and
not any environmental
hazards.
By clustering the patients care
they will be able to have long
breaks between treatments.
Collaborating with the
patient’s entire health care
team to allow for a nap
throughout the day to provide
proper rest that wasn’t
received the night before.
Decreasing the level of
EVALUATION

Patient reported a pain level
of 3 out of 10 before and
after ambulation. Their pain
did not affect the ambulation
intervention and pain
medication was not needed.
Patient’s confidence was
boosted as they surpassed
the goal of 200 feet and
ambulated 400 feet on post
op day 3.

Patient was able to take an
undisturbed nap from 1000
till 1115 due to the
collaboration of their health
care team to cluster care.
This improved the patient’s
level of comfort and reduced
their grogginess. At the end
of the shift the patient no
longer suffered from
was irritable when
questioned
throughout day.
1.
Acute pain related abdominal
incision as evidence by patient
discomfort
a. Sub: “It hurts a little
where my wound is,
but not too much.
It’s 3 out of 10.”
b. Patient’s abdominal
muscles were flexed
when incision site
was assessed, and
grimaced slightly
when the periwound
area was palpated.
day.

Patient will report a pain less
than 3 out of 10 by end of
shift. (At 1400 on 06/18/2012)



Reduce amount of ambulation
by providing a bedside
commode.
Provided a distraction from
pain through therapeutic
conversation about school and
social life.
Educated patient that
ambulation will facilitate
healing and circulation.



2
sensory input decreases the
patient’s level of fatigue and
discomfort allowing for a
quiet and relaxed
environment.
Providing a bedside commode
reduced the amount of fall risk
the patient would encounter
per day and facilitate proper
elimination if no assistance
was available for ambulation
to bathroom.
Therapeutic conversation
distracted the patient
momentarily from their pain
as this was noted by the
increased interest in
conversation.
Patient was unaware of the
benefits of ambulation and
how it prevents soreness and
helps facilitate recovery
discomfort.
*(patient neglected to take their
prescribed prn pain medication of
hydromorphone. Patient was
concerned it would slow
digestion and induce grogginess,
therefore distraction, ambulation,
and the reducing of ambulation
distances was utilized).
 Patient was pleased with the
distractive measures of
therapeutic conversation.
Patient also understood the
benefits of ambulation and
was almost immediately
driven to ambulate. Patient
also liked the fact that a
bedside commode was
present to reduce how far
they had to walk and was
encouraged to use the
bathroom more.