NURSING CARE PLAN

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: > Impaired bed Trauma After the rotation  determine  To identify After the rotation
mobility related (slipping) and nursing diagnoses that causative/ and nursing
“Hindi siya to pain secondary intervention the contribute to contributing intervention the
makatagilid to bone fracture at significant other immobility (e.g. factors. significant other
sumasakit daw musculoskeletal pelvic bone of the patient fractures, of the patient
ung bali niya sa impairment. will: hemi/para/tetra/q will:
may bewang Disruptions of uadripegia)
kapag periosteum and a. Verbalize  Note individual a. Verbalize
gumagalaw” as blood vessels understanding risk factors and understanding
verbalized by the of the current situation, of the
sn of the patient. Destruction if situation /risk such pain, age, situation /risk
tissue factors, general factors,
Objective: individual weakness, individual
Bleeding occurs therapeutic debilitation therapeutic
 Impaired regimen and  Determine regimen and
ability to turn Pain safety perceptual/ safety
side to side measures. cognitive measures.
 Impaired Impaired bed b. Demonstrate impairment to b. Demonstrate
ability to mobility techniques/ follow directions techniques/
move from behaviors that  Determine  To assess behaviors that
supine to will enable functional level patients will enable
sitting vise safe classification functional safe
versa. repositioning ability repositioning
 (+) presence c. Maintain  Note presence of c. Maintain
of pelvic position of complications position of
fracture function and related to function and
 (+) General skin integrity immobility skin integrity
of the patient of the patient
weakness  Observe skin for  To reduce
 Tremors as evidenced friction, as evidenced
reddened
noted on left by absence of maintain safe by absence of
areas/shearing.
arm and contractures, skin/tissue contractures,
Provide
hands foot drop, pressures and foot drop,
appropriate
decubitus, etc. wick away decubitus, etc.
pressure to relief
moisture
 Provide regular  To prevent
skin care if complications
appropriate
 Assist with  To promote
activities of optimal level
hygiene, of functioning
toileting,
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: > Impaired Hypertension After the  Determine  To identify After the rotation
physical ˇ rotation and diagnosis that causative/ and nursing
“Hindi na mobility related Occlusion within nursing contributes to contributing intervention the
makagalaw si to vessels of the brain intervention the immobility factors. patient will:
nanay simula Neuromuscular parenchyma patient will: (e.g. fractures,
nung na-stroke impairment ˇ hemi/ para/ c. Maintain
siya ” as Disruption of blood a. Maintain tetra/ position and
verbalize by the supply in the brain position and quadriplegia) function and
son of the patient area function and  Assess skin integrity
ˇ skin nutritional as evidenced
Obective: Tissue and cell integrity as status and S/O by absence of
necrosis evidenced others report of contractures,
 (+) General ˇ by absence energy level. foot drop,
 body Destruction of of  Determine  To assess decubitus and
weakness Neuromuscular contractures, degree of functional so forth.
 Tremors junctions foot drop, immobility in ability d. S/O will
noted on left ˇ decubitus relation to demonstrate
arm and Interruption in and so forth. functional level techniques/
hands transportation of b. S/O will scale behaviors that
 Inability to electrical impulses to demonstrate  Assist or have  To prevent will enable
perform the neuromuscular techniques/ significant complication safe
gross/fine receptors behaviors other reposition repositioning
motor skills ˇ that will client on a
 (+) Paralysis MYALGIA/QUADRI enable safe regular
of left side of OR HEMIPLEGIA repositionin schedule (turn
the body g to side every 2
 functional hours) as
level scale: ordered by the
4 (does not physician
participate in  Provides safety  To provide
activity) measures (side safety
rails up, using
pillows to
support body
part)
 Encourage  Enhances
patient’s S/O’s commitment
involvement in to plan
decision optimizing
making as outcomes
much as
possible
 Involve S/O in  To impart
care, assisting health
them to learns teaching.
ways of
managing
problems of
immobility.
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Self care deficit : Hypertension After the rotation  Provide enteric  To meet After the rotation
“Simula nung na hygiene, ˇ and nursing nutrition VIA patient’s need and nursing
i-stroke si nanay, dressing and Occlusion within interventions. The NG Tube for an interventions.
na bedridden na grooming, vessels of the patient should: feeding. High adequate The patient
siya feeding and brain a. meet all fowlers for at nutritional should:
toileting related parenchyma therapeutic self least 15 intake. f. meet all
Objective: to ˇ care demands in minutes after therapeutic
(+) NGT insertion Neuromuscular Disruption of a complete feeding. self care
impairment blood supply in absence of self  Careful I/O  To establish demands in a
Patient is unable the brain area care agency Monitoring and careful complete
to: ˇ b. ABSENCE OF apply necessary assessment on absence of
[HYGIENE] Tissue and cell S&S OF dietary patients fluid self care
 Access and necrosis NUTRITIONAL restrictions and agency
prepare bath ˇ DEFICIT. electrolyte g. ABSENCE
supplies Destruction of [Adequate . balance. OF S&S OF
 Wash body Neuromuscular nutritional  Change  To prevent NUTRITION
 Control junctions intake] position at least decubitus AL
washing ˇ c. GOOD SKIN ONCE every ulcerations. DEFICIT.
mediums Interruption in TURGOR, two hours or [Adequate
[DRESSING transportation of NORMAL more often nutritional
AND electrical URINE when needed. intake]
GROOMING] impulses to the OUTPUT,  Provide  To protect the h. GOOD SKIN
 Obtain neuromuscular ABSENCE OF padding for the patient’s skin TURGOR,
articles for receptors EDEMA, elbows, needs, integrity NORMAL
clothing ˇ HYPER AND ankles and maintaining URINE
 Put on clothes MYALGIA/QU HYPOVOLEMI other areas for his first line OUTPUT,
ADRI OR A [Fluid and possible skin of defense ABSENCE
 Maintain
HEMIPLEGIA Electrolyte abrasion. against OF EDEMA,
appearance at
balance] sickness and HYPER
an acceptable
d. ABSENCE OF infection. AND
level
DECUBITUS  An adult diaper  To prevent HYPOVOLE
[FEEDING]
ULCERS AND should be soiling of bed MIA [Fluid
 Prepare/obtain FOUL ODORS and
food for WORN at all sheets,
IN BETWEEN times. Change clothes and Electrolyte
ingestion LINENS/CLOT balance]
 Handle the diaper as linens
HING AND soon as patient providing i. ABSENCE
utensils SKIN [Clean, OF
defecated. maximum
 Bring food to Intact skin and DECUBITUS
comfort and
mouth mucus ULCERS
prevention of
 Chew and membrane] skin irritation AND FOUL
swallow up e. ABSENCE OF if feces ODORS IN
food ABDOMINAL remain in BETWEEN
 Pick up food AND contact with LINENS/CL
[TOILETING] BLADDER the patient’s OTHING
Go to the toilet DISTENTION, skin for a AND SKIN
RECTAL long time. [Clean, Intact
FULLNESS  Promote an  To conserve skin and
AND Environment energy mucus
PRESSURE, conducive to promoting membrane]
PAIN IN rest and rest and j. ABSENCE
DEFECATION [ recovery. recovery. OF
Meeting toileting Decrease ABDOMINA
demands ] stimuli and L AND
Metabolic BLADDER
demand of the DISTENTIO
body. N, RECTAL
 Passive ROM  This is to FULLNESS
Exercises Early improve AND
morning once a circulation, PRESSURE,
day, 10 times reducing the PAIN IN
targeting both risk of DEFECATIO
upper and atheromatous N [ Meeting
lower formation. toileting
extremities. demands ]
> Lastly, Do health 10. To educate
teaching when S/O the S/O what
is at the optimum factors have
level to receive contributed to the
information. client’s illness
and educating
them to decrease,
if not totally
eliminate those
contributory
factors to prevent
recurrence of the
disease and
promote change
for a healthy
lifestyle.