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Clinical Form 4 Present-State “WEB” Physio Basic 1 Pain & Comfort Risk for isolation, loss of independence, risk for depression, possible lack of support system fall risk Increased fatigue 2 6 3 7 18 Physio Basic Activity, Immobility, Self-care Increased fatigue, decreased mobility, decreased activity, reorganization of self-care, decreased ability to perform ADL’s, possible inadequate self-care 5 4 Behavioral Patient/family education 19 In need of continuing education Client’s “Story” 9 Physio Basic Nutrition & Elimination 17 Decreased fluid intake, decreased food intake, decreased urine output 10 11 Behavioral Coping, Communication, Psychosocial Increased infection risk, Decreased comfort 8 Safety Risk Factors Fall, Infection, DVT, etc. 12 16 K.C., 30 year old, paraplegic female Main concern: maintain and reorient self-care habits independently in the home How affects life: creating good habits takes time and can be inconvenient Physiology: schedule I&O, maintaining infection prevention, possible impact on mental state Community Support/connections, Cultural concerns Physio Complex Health System Respiratory & Tissue perfusion Access issues, Insurance Decreased tissue perfusion, risk for respiratory distress, decreased circulation 14 13 Physio Complex Perioperative wound/skin care, Thermoregulation Decreased thermoregulation, risk for skin breakdown 15 Physio Complex Family Neurological, Acid/base balance, Fluid/electrolyte balance, Medication management Support concerns pH change, elecrolyte imbalance, paraplegic Connections • • • • • • • • • • • • • • • • • • • 1. Cause and effect relationship 2. Cause and effect relationship 3. Cause and effect relationship 4. Recognize signs for depression and/or isolation 5. Decreased activity/mobility 6. Cause and effect relationship 7. Re-teaching hygienic practices and mobility lessons for decreased fall risk 8. Cause and effect relationship 9. Cause and effect relationship 10. Self care connection 11. Cause and effect relationship 12. Decreased mobility concern 13. Fluid imbalance 14. Cause and effect relationship 15. Continuing education needed for connection between electrolyte balance and pH to nutrition and lifestyle. 16. Cause and effect relationship 17. Not moving and repositioning 18. Cause and effect relationship 19. Cause and effect relationship