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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
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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