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Pt initials: Z.G. Pt info: 4 yo F Chief complaint/diagnosis: Epilepsy …

- - - - INTERVENTIONS:
        Intervention #1: Assess muscle strength and other factors affecting balance, mobility, and endurance (Ackley and Ladwig, 2017, p. 621).
        Intervention #2: Monitor and record the client's response to activity, such as pulse rate, blood pressure, dyspnea, skin color, and subjective report (Ackley and Ladwig, 2017, p. 621).
        Intervention #3: Perform passive ROM exercises at least twice a day unless contraindicated (Ackley and Ladwig, 2017, p. 622).
        Intervention #4: Use gestures and nonverbal cues when helping clients move if they are anxious or have difficulty understanding and following verbal instructions (Ackley and Ladwig, 2017, p. 623).
        Intervention #5: If the client is mainly immobile, provide opportunities for socialization and sensory stimulation (Ackley and Ladwig, 2017, p. 623).
        
        EVALUATION:
        Goal not met. Pt slept for most of the day (barrier to goal completion) so ROM exercises were not able to be completed while I was there which led to no change in activity level or muscle strength. This goal may need to be changed to, "The pt's parents will report decreased sleepiness during the day and a mild increase in activity level by discharge on 10/11/20."
- - - - INTERVENTIONS:
        Intervention #1: Establish a therapeutic relationship with the client (Ackley and Ladwig, 2017, p. 858).
        Intervention #2: Observe for barriers to social interaction (Ackley and Ladwig, 2017, p. 858).
        Intervention #3: Promote social interactions (Ackley and Ladwig, 2017, p. 858).
        Intervention #4: Assist the client's family in identifying activities that encourage socialization (Ackley and Ladwig, 2017, p. 858).
        Intervention #5: Identify available support systems and involve those individuals in the client's care (Ackley and Ladwig, 2017, p. 858).
        
        EVALUATION:
        Goal met. While the patient was awake, she made eye contact with her nurse, her mom, and I when we were talking to her. This eye contact let us know that she was listening to us and promoted the concept of social interaction. One intervention I could have added to reach my goal was when she was awake, I could have used one of her favorite toys to get her attention and try to get her to make eye contact and interact with the toy and I.
- - - - INTERVENTIONS:
        Intervention #1: Evaluate all clients for fall risk daily and take appropriate actions to prevent falls (Ackley and Ladwig, 2017, p. 560).
        Intervention #2: Educate the family on how to recognize and report concerns about safety issues (Ackley and Ladwig, 2017, p. 560).
        Intervention #3: Place an "at risk for injury" client in a room that is near the nurse's station (Ackley and Ladwig, 2017, p. 560).
        Intervention #4: Involve family in helping to provide a culture of safety (Ackley and Ladwig, 2017, p. 560).
        Intervention #5: Teach parents the need for close supervision (Ackley and Ladwig, 2017, p. 560).
        
        EVALUATION:
        Goal met. The patient remained free from injury throughout the entirety of my shift on 10/10/20. One intervention I could have added to reach my goal was I could have talked to my nurse about involving PT in her plan of care at the hospital. PT would serve to increase her muscle strength which would therefore prevent injuries associated with hypotonia and most other injuries in general.