B.
PLANNING
Nursing Care Plans
ANALYSIS
Subjective:
“masakit ang binti ko”
 Pain scale of 7/10
Objective:
 Grimace
 Increased perspiration
 Guarding behavior at the
site of tissue damage (right
thigh)
Diagnosis:
Acute pain r/t tissue damage
Scientific Explanation:
Due to surgical procedure, the tissue
has been damage that stimulates the
release of pain receptors at the site
such as prostaglandin, serotonin and
bradykinin.
POSTOPERATIVE
PLANNING
Within 30minutes to 1 hour of
rendering proper nursing
interventions the client’s pain will be
alleviated from a scale of 7/10 to
2/10.
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February 23-25, 2010
INTERVENTION EXPECTED OUTCOME
Independent: After 30minutes to 1 hour of
 Assess level of pain, rendering proper nursing
determining the intensity at its interventions the client’s pain will be
best or worst. alleviated from a scale of 7/10 to
(Systematic ongoing 2/10.
assessment and documentation
provide direction for the pain As evidence by:
treatment.)  Loss of guarding behavior
 Teach relaxation technique such  No grimace
as deep breathing exercise,
pursed lip breathing and muscle
relaxation.
(A relaxation technique reduces
tension and anxiety which
potentiates the perception of
pain).
 Provide distractions like
conversation.
(Destruction helps increase
relaxation and ability to cope
with discomforts.)
 Divert client into activities like
reading newspapers.
(To divert feelings of pain)
Dependent/Collaborative:
 Administered analgesics as
prescribed.
(Analgesics has pharmacological
action that decreases pain)
 ANALYSIS
Subjective:
Ø nursing intervention the client will be
Objective:
 w/ incision in the right thigh
 w/ open wound at the right
buttocks
 presence of pressure ulcer
at the back
 presence of internal fixator
at the right thigh
Diagnosis:
Impaired skin integrity r/t mechanical
factors (accident, surgical procedure
and pressure)
Scientific Explanation:
Due to accident happened to the
patient he has developed
osteomyelitis that requires surgical
debridement that results to an
incision of the right thigh, due also to
his condition that requires bed rest
he has developed pressure ulcer at
the back.
PLANNING
Within 3 hours of rendering proper
able to demonstrate and state
measures in improving the impaired
site.
INTERVENTION EXPECTED OUTCOME
Independent: After 2 hours of rendering proper
 Assess the site of skin nursing intervention the client will be
impairment and determine able to demonstrate and state
the cause. measures in improving the impaired
(This will provide basis for site.
the appropriate
management of the As evidenced by:
condition)  Verbalized understanding of
 Maintain the head of the the interventions given
bed at the lowest degree  Able to state different
possible or use lift devices, measures to protect and
pillows and foam wedges. heal the skin.
(To prevent pressure at the
site)
 Encourage the client not to
position his self at the
impaired site.
(To protect against adverse
effect of external
mechanical forcers such as
pressure and friction)
 Advice the patient to
monitor site of impaired skin
at least once daily for color
changes, redness, swelling,
warmth, pain.
(Systemic inspection can
identify impending problem
early)
 Move the client from side to
side at least every 2-3 hours.
(For management of
pressure ulcer to minimize
the pressure at the site and
provide air)
 Tell the client to avoid
massaging around the site.

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 (Massage may lead to deep
tissue trauma)
 Educate the client regarding
proper wound care and
dressing.
(To be knowledgeable
enough and independent
when have been discharged)
 Educate the client to be
cautious enough when
voiding or eliminating.
(To prevent direct contact to
body secretions that may
increase the possibility of
infection)
 Advice the client to increase
Vitamin C and protein
intake.
(To help in strengthening of
immune system and healing
of wound)

Dependent/Collaborative:
 Irrigation of wound
aseptically.
(To prevent development or
growth of microorganisms
at the site)
 Administer antibiotics as
prescribed such as
gentamicin.

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 ANALYSIS
Subjective:
“nahihirapan akong tumayo at
gumalaw ng maayos”
Objective:
 Limited ability to perform
gross motor skills such as
walking and sitting alone
 Limited ROM
 Difficulty in turning position
from side to side
 Remarkable gait changes
(decreased walking speed
and difficulty intiating gait)
 Presence of an internal
fixator at the right thigh
 Use of crutches and wheel
chairs
Diagnosis:
Impaired physical mobility r/t loss of
integrity of bone structures
Scientific Explanation:
Due to the presence of internal
fixator and surgical procedure that
was done recently (debridement) the
patient still cannot manage to move
well as a result of bone invasion.
PLANNING
Within 2 to 4 hours of rendering
proper nursing intervention the client
together with the significant others
will be able to demonstrate different
measures to increase physical
mobility of the client.
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INTERVENTION EXPECTED OUTCOME
Independent: After 2 to 4 hours of rendering proper
 Screen for mobility skills in nursing intervention the client
the following order: (1) bed together with the significant others
mobility; (2) supported and will be able to demonstrate different
unsupported sitting; (3) measures to increase physical
transition movements such mobility of the client.
as sit to stand, sitting down
and transfers, and (4) As evidenced by:
standing and walking  Verbalize willingness in
activities. doing the said activities
(Abilities of the client should  Demonstrate use of adaptive
be assessed to determine devices (wheelchair and
how best to facilitate crutches) to increase
movement and protect the mobility
nurse from harm)  Demonstrate the different
 Determine the cause of ROM exercises correctly
impaired mobility.
(To provide the nurse with
enough data)
 Monitor and record client’s
ability to tolerate activity
and use of all four
extremities, note PR, RR, BP,
and skin color before and
after the activity.
(To evaluate client’s
capability and response)
 Demonstrate and perform
passive ROM exercises with
the patient together with
the significant others.
(These exercises help
reverse weakening and
atrophy of muscles)
 Assist client in changing
position such as from lying
to sitting, sitting to standing
 etc. for every 2 hours.
(Turning and shifting weight
increase circulation and help
prevent skin breakdown)
 Encourage ambulation and
provide assistance as
necessary.
(Ambulation maintains, and
improve circulation, and also
helps prevent muscle
atrophy and maintains
bowel function)
 Use a gait walking
belt/wheelchair when
ambulating client.
(To prevent/reduce
incidence of injuries)
 Increase client’s
independence to perform
ADLs and discouraged
helplessness when he gets
stronger.
(Providing necessary
assistance may promote
dependence and loss of
mobility)

Dependent/Collaborative:
 Obtain any assistive devices
needed for activity such as
gait belt, walker, crutches
and wheelchair before
activity begins.
(Activity devices can help
increase mobility and to
have a balance)
 Consult with Physical
Therapist for further

33
 evaluation, strength
training, gait training, and
development of mobility
plan.
(trainings such as gait
training etc., can help to
improve balance and
coordination)

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 ANALYSIS
Subjective:
“nag-aalala ako baka hindi na bumalik
sa dati ang paa ko”
Objective:
 Poor eye contact
 Increased perspiration
 Irritable
 Weak in appearance
 Presence of internal fixator
at the right thigh
Diagnosis:
Anxiety r/t change in health status
Scientific Explanation:
Client experiences anxiety due to
previous surgery, his health status
was changed and he’s not sure of
what will happen to him when he will
be discharged.
PLANNING
Within 2-3 hours of rendering proper
nursing interventions the client’s
level of anxiety will be minimized.
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INTERVENTION EXPECTED OUTCOME
Independent: After 2-3 hours of rendering proper
 Assess the client’s level of nursing interventions the client’s
anxiety and physical level of anxiety will be minimize.
reactions to anxiety.
(Anxiety is known to As evidenced by:
extensify physical  Verbalize decrease in
symptoms) subjective distress
 Provide a quiet environment  Able to establish eye contact
with diversion.  Minimize sweating
(Excessive noise increases  Demonstrate ability to
anxiety, involvement in a reassure self
quiet activity can be
soothing for the patient)
 Use empathy to encourage
the client to interpret the
anxiety symptoms as
normal.
(This will facilitate
therapeutic communication
to fatherly assess client’s
feelings)
 Teach client regarding deep
breathing exercises.
(Deep breathing exercise
can help the client to be
calm and relaxed)
 Encourage the client to use
positive self talk such as
“gagaling din ako”, “kaya ko
to”.
(Changing negative
statements to positive
statements in some way
may help to decrease
anxiety)
 Provide backrubs or
massage for the client to
 decrease anxiety.
(Massage significantly
decrease the anxiety or
perception of tension)
 Use therapeutic touch and
healing touch techniques.
(Anxiety was significantly
reduced in therapeutic
touch placebo condition,
healing touch is one of the
interventions readily
available to reduce anxiety)
 Use guided imagery to
decrease anxiety.
(Anxiety was decreased with
the use of guided imagery
for post-op pain)
 Explain all the activities,
procedures and issues that
involved the client. Use non
medical terms, and calm and
slow speech.
(To increase coping skills
because they know what to
expect)
 Explore coping skills
previously to relieve anxiety.
(methods of coping with
anxiety that has been
successful in the past are
likely to be helpful again)

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 ANALYSIS
Subjective:
Ø nursing intervention the client will be
Objective:
 w/ incision in the right thigh
 presence of internal fixator
at the right thigh
 limited body movement
Diagnosis:
Risk for infection r/t tissue
destruction and increased
environmental exposure
Scientific Explanation:
There is still a risk for infection due to
damage tissue as a result of
debridement and unsanitary
exposure to hospital environment,
microorganisms can easily enter the
site.
PLANNING
Within 2-4 hours of rendering proper
able to remain free from signs and
symptoms of infection.
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INTERVENTION EXPECTED OUTCOME
Independent: After 2-4 hours of rendering proper
 Assess skin for color, texture nursing intervention the client will be
moisture and turgor able to remain free from signs and
(Intact skin is nature’s first symptoms of infection.
line of defense against
microorganisms entering the As evidenced by:
body)  Vital signs w/in normal
 Monitor the client’s vital range:
signs specifically body BP: 110/80
temperature. PR:85
(Change in vital signs such RR: 20
as in temperature may T: 36.1◦C
signify presence of infection)  Site remains free from any
 Use appropriate hand signs of infection such as
hygiene when attending to swelling.
patient or when doing
procedures.
(To reduce/ prevent
transmission of
microorganisms)
 Ensure sterility of
materials/supplies when
performing procedures such
as wound care/dressing.
(To prevent contamination)
 Ensure the client’s hygienic
care with hand washing,
bathing, and oral care.
(Hygienic measure is
important to minimize/wash
out certain microorganism
in the client’s body that may
cause infection)
 Encourage the client to
increase fluid intake.
(Fluid intake facilitates
elimination that may
 decrease the possibility of
having infection)
 Encourage a balance diet,
emphasizing proteins, fatty
acids and vitamins (C, B12,
E)
(To boost immune system
and strengthens the body)

Dependent/Collaborative:
 Administered antibiotics as
prescribed.
(To prevent infection)

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