![]() When getting out of bed, the patient will have adequate cerebral perfusion as evidenced by a heart rate of fewer than 120 beats per minute and blood pressure of 90/60 mm Hg or greater (or within 20 mm Hg of the patient’s normal range) immediately after a position change, normal skin color, dry skin, and absence of vertigo and syncope, with a return of heart rate and blood pressure to resting levels within 3 minutes of the position change. ![]() The patient will engage in diversional activities and relates the absence of boredom.The patient and caregivers will develop realistic goals for independence and participation in self-care.The patient will state the return of normal pattern and character of bowel elimination within 3-5 days of this diagnosis.The patient will verbalize knowledge of strategies that promote bowel elimination. ![]() The patient will relate satisfaction with sexuality and understanding of the ability to resume sexual activity.The patient will perform exercises independently, comply with the prophylactic therapy, and maintain an intake of 2-3 liters per day of fluid unless contraindicated.The patient will have adequate peripheral perfusion as evidenced by normal skin color and temperature and adequate distal pulses (greater than 2+ on a 0-4+ scale) in peripheral extremities.It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. Changes in vital signs, such as increased heart rate or decreased blood pressureįollowing a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with prolonged bed rest based on the nurse’s clinical judgement and understanding of the patient’s unique health condition.Presence of pressure ulcers or skin breakdown.Feelings of boredom, frustration, or restlessness.Difficulty sleeping or changes in sleep patterns. ![]()
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