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Pt initials: H.G. Pt info: 4 yo M Admit date: 09/04/20 Chief…

- - - - SMART GOAL:
        The patient will complete his PT exercises correctly and safely every day (Ackley and Ladwing, 2017, p. 122).
        
        INTERVENTIONS:
        Intervention #1: Assess the client daily for appropriateness of activity and bed rest orders (Ackley and Ladwig, 2017, p. 123).
        Intervention #2: Observe and document skin integrity several times a day (Ackley and Ladwig, 2017, p. 124).
        Intervention #3: Refer the client to physical therapy to help increase activity levels and strength (Ackley and Ladwig, 2017, p. 124).
        Intervention #4: Provide emotional support and encouragement to the client to gradually increase activity (Ackley and Ladwig, 2017, p. 124).
        Intervention #5: Observe for pain before activity (Ackley and Ladwig, 2017, p. 124).
        Intervention #6: Obtain any necessary assistive devices or equipment (walker) needed before ambulating the client (Ackley and Ladwig, 2017, p. 124).
        
        EVALUATION: Goal unmet
        Pt was unable to complete his PT for the day because he was in a signifiant amount of pain (barrier to goal completion) with movement of his left leg. My previous goal needed to be changed to "My patient will wiggle his toes every 30 minutes and will complete his PT exercises as often as tolerated."
- - - - INTERVENTIONS:
        Intervention #1: Assess the client's level of anxiety (Ackley and Ladwig, 2017, p. 141).
        Intervention #2: Use empathy to encourage the client to interpret the anxiety symptoms as normal (Ackley and Ladwig, 2017, p. 141).
        Intervention #3: If irrational thoughts or fears are present, offer the client accurate information (Ackley and Ladwig, 2017, p. 141).
        Intervention #4: Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech then validate the client's understanding (Ackley and Ladwig, 2017, p. 141).
        Intervention #5: Use therapeutic touch and healing touch techniques (Ackley and Ladwig, 2017, p. 141).
        
        EVALUATION: Goal met
        Right before surgery and post-surgery (before discharge), the patient began to show signs of decreased anxiety such as smiling and being relaxed enough to sleep. While awake, the patient's posture was more relaxed (where in contrast, at the height of his anxiety, his muscles were rigid). One intervention I could have added to reach my goal was I could have called the child life specialist and had him/her use distraction techniques to reduce my patient's anxiety.
- - - - INTERVENTIONS:
        Intervention #1: Assess the client for emotional influences that may be contributing to constipation (anxiety and stress) (Ackley and Ladwig, 2017, p. 256).
        Intervention #2: Complete a physical examination; palpation for abdominal distention, percussion for dullness, and auscultation of bowel sounds) (Ackley and Ladwig, 2017, p. 256).
        Intervention #3: Review the client's current medications (Ackley and Ladwig, 2017, p. 256).
        Intervention #4: Encourage physical activity within the client's current ability to mobilize. Encourage turning and changing position in bed if immobile (Ackley and Ladwig, 2017, p. 257).
        Intervention #5: Instruct the client on normal bowel function and the need for adequate fluid and fiber intake and activity (Ackley and Ladwig, 2017, p. 259).
        
        EVALUATION: Goal unable to assess.
        The patient did not have a bowel movement during my shift but he may have had one when he got home that day. One intervention I could have added to reach my goal was I could have instructed my patient and his dad to increase his fiber intake for the next couple of days to promote defecation.