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Lieblingsgetränke werden zur Steigerung der Flüssigkeitszufuhr immer bereitgestellt.
Maßnahme
Pflegeziel
Ressource
Pflegeproblem
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Herr Seidel (97 kg) nimmt 3 kg ab.
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Die Hautfalten bleiben trocken und entzündungsfrei.
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Pat. erhält eine Peroneus-Schiene.
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Pat. nimmt eine Schonhaltung ein.
Pflegeproblem.
Maßnahme.
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Tag-Nacht-Rhythmus ist gestört.
Pflegeproblem.
Maßnahme.
Ressource
Pflegeziel
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Bew. muss Antirutschsocken anziehen.
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Vor dem Schlafengehen werden gleiche Einschlafrituale durchgeführt.
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PK leitet die Teilwaschung an und übernimmt Rasur
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Pat. hat durch langes Liegen Dekubitus.
Pflegeproblem.
Maßnahme.
Ressource
Pflegeziel
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Bew. zeigt Interesse an Gesellschaft und Unterhaltung.
Ressource
Pflegeziel
Maßnahme
Pflegeproblem
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Bew. verspürt gelegentlich eigenständig Harndrang.
Ressource
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Bew. kann mit Hilfe von Gehhilfen kurze Strecken noch selbstständig gehen.
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Pat. isst die Mahlzeiten meistens mit Appetit fast vollständig auf.
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Bew. ist in der Lage, Schmerzen zu artikulieren und Schmerzzonen zu zeigen.
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Schmerzerfassung mittels Schmerzskala durchführen, Abklärung mit beh. Arzt
Maßnahme
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Ressource
Pflegeziel
5
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25
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Bew. werden Zwischenmahlzeiten und Lieblingsgetränke angeboten.
Maßnahme
Pflegeproblem
Ressource
Pflegeziel
5
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25
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Im Zimmer werden Orientierungshilfen, Fotos und Namensschilder angebracht.
Maßnahme
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Pflegeziel
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Stolperfallen werden beseitigt.
Maßnahme
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Pflegeziel
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25
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Informationen werden einfach formuliert und in kleinen Schritten gegeben.
Maßnahme
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Pflegeziel
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25
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Bew. kann zukünftig wichtige Anweisungen verstehen und in einfachen Worten wiederholen.
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Maßnahme
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Bew. ist den Jahreszeiten gemäß gekleidet.
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Maßnahme
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Bew. geht zum Erhalt der Selbstständigkeit zweimal täglich in Begleitung durch den Flur.
Pflegeziel
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Pflegeproblem
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Bew. nimmt zukünftig alle verordneten Medikamente korrekt ein.
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Die Schmerzen liegen bis morgen unter 3/10.
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Pat. fürchtet sich vor der Blutabnahme.
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Pflegeziel
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Bew. ist nicht in der Lage, sich selbst zu waschen.
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Maßnahme
Pflegeziel
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25
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Frau Kim hat 2 kg Körpergewicht abgenommen. Es besteht die Gefahr einer Mangelernährung.
Pflegeproblem
Ressource
Maßnahme
Pflegeziel
5
10
15
20
25
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Herr Klein kann aufgrund eines Bandscheibenvorfalls nicht allein gehen.
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Maßnahme
Pflegeziel
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25
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Frau Schmidt leidet an einer Unverträglichkeit.
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Maßnahme
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25
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