Clinical Practicum Worksheet: Nursing Care Plan

Department of Health Academy (DOHA) Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING

4 July to 7 October 2016
Clinical Practicum Worksheet

Nursing Care Plan
Patient's Name: Lugto, Jose
Age: 84
Diagnosis: PTB; HCVD with left sided hemiplegia; pelvic fracture
ASSESSMENT
Subjective cues:
"Isa siya sa mga
bedbound na
pasyente namin
Ma'am. Talagang
lahat ikaw ang
gagawa para sa
kaniya", as
verbalized by Sir
Mario (houseparent).
Objective cues:
Inability to feed,
dress, bathe, groom,
perform toileting
tasks, transfer from
bed to wheelchair,
and ambulate
independently
Katz score: 0
With left sided
weakness and
NURSING
DIAGNOSIS
Self-Care Deficit in
bathing/ hygiene,
dressing/ grooming,
feeding, toileting and
ambulating related to
neuromuscular
impairment,
secondary to
cerebrovascular
accident (CVA), and
musculoskeletal
impairment,
secondary to pelvic
fracture.
PLANNING
Long-term
goal:
The client will
perform selfcare activities
within physical
limitations and
activity
restrictions
imposed by
current
diagnosis and
treatment plan.
Short term
goal:
The caregiver
will provide
assistance with
Gender: Male
Cottage: Matatag
NURSING
INTERVENTIONS
RATIONALE
Assess ability to carry out

ADLs (e.g., feed, dress, groom,
bathe, toilet, transfer, and
ambulate) on regular basis.
Assess patients need for
assistive devices.
Determine the aspects of self

care that are problematic to
the patient. The patient may
only require assistance with
some self-care measures.
This increases independence in
ADLs performance.
Set short-range goals with

patient.
Assisting the patient to set

realistic goals will decrease
frustration.
Encourage independence, but

intervene when patient cannot
perform.
Use consistent routines and
allow adequate time for
patient to complete tasks.
An appropriate level of
assistive care can prevent
injury with activities without
causing frustration.
This helps patient organize and
carry out self-care skills.
Provide positive reinforcement

for all activities attempted;
Submitted by:
EVALUATIO
N
Goal partially
met. The client
was able to set
short range
goals in order
to perform selfcare activities
within physical
limitations and
activity
restrictions
imposed by
current
diagnosis and
treatment plan.
Goal met. The

caregiver was
able to provide
assistance with
Orlea A. Francisco, R.N.
M.A.N.
Nurse II - San Lazaro Hospital
muscle atrophy
Muscle strength
grade: 3 (fair) complete range of
motion against
gravity with no
resistance
ASSESSMENT
activities of
daily living
when
necessary.
NURSING
DIAGNOSIS
PLANNING
note partial achievements.

* Feeding:
Assure that consistency of
diet is appropriate for patients
ability to
NURSING
INTERVENTIONS
This provides the patient with

an external source of positive
reinforcement.
activities of
daily living
when
necessary.
Mechanical problems may

prohibit the patient from
eating.
RATIONALE
EVALUATIO
N
chew and swallow.

Provide patient with
appropriate utensils (e.g.,
drinking straw, food guard,
nonskid place mat) to aid in
self-feeding.
These items increase

opportunities for success.
Aspiration precaution.
Place patient in optimal
position for feeding, preferably
sitting up in a chair; support
arms, elbows, and wrists as
needed.
* Dressing/grooming:
Provide privacy during
dressing.
Patients may take longer to

dress and may be fearful of
breaches in privacy.
These reduce energy

expenditure and frustration.
Submitted by:
M.A.N.
Provide frequent
encouragement and assistance
as needed with dressing.
The need for privacy is
fundamental for most patients.
* Bathing/hygiene:
Maintain privacy during
bathing as appropriate.
Hurrying may result in

accidents and the energy
required for these activities
may be substantial.
Instruct patient to select bath

time when he or she is rested
and unhurried.
Assist with brushing teeth and

shaving, as needed.
Assist patient to perform

minimal oral-facial hygiene as
soon after rising as possible.
ASSESSMENT
NURSING
DIAGNOSIS
PLANNING
NURSING
INTERVENTIONS
RATIONALE
* Toileting:
Evaluate or document previous
and current patterns for
toileting; institute a toileting
schedule that factors these
habits into the program.
Assist patient in removing or
replacing necessary clothing.
* Transferring/ambulation:
Plan teaching session for
EVALUATIO
N
The effectiveness of the bowel

or bladder program will be
enhanced if the natural and
personal patterns of the
patient are respected.
Clothing that is difficult to get
in and out of may compromise
a patients ability to be
continent.
Submitted by:
M.A.N.
transferring/walking when
patient is rested.
Encourage patient to use the
stronger side (if appropriate)
as best as possible.
Allow patient to work at own

rate of speed
Assist patient in doing passive

range of motion exercises.
Tasks require energy. Fatigued

patients may have more
difficulty and may become
unnecessarily frustrated.
Stroke patients experience
weakness in their dominant
side; therefore it will be
necessary for them to develop
muscle strength and
coordination on the stronger
side.
It will take time for the patient
to learn and then gain
confidence in his or her ability
to perform these new self-care
measures.
To prevent further muscle
atrophy and neglect of the
weak side of the body.
Submitted by:
M.A.N.

Clinical Practicum Worksheet: Nursing Care Plan

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Department of Health Academy (DOHA) Gerontology Nurses Association of the Philippines (GNAP)

TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING

Clinical Practicum Worksheet

Assess ability to carry out

Determine the aspects of self

Set short-range goals with

Assisting the patient to set

Encourage independence, but

Provide positive reinforcement

Goal met. The

Orlea A. Francisco, R.N.

note partial achievements.

This provides the patient with

Mechanical problems may

chew and swallow.

These items increase

Patients may take longer to

These reduce energy

Orlea A. Francisco, R.N.

Hurrying may result in

Instruct patient to select bath

Assist with brushing teeth and

Assist patient to perform

The effectiveness of the bowel

Orlea A. Francisco, R.N.

Allow patient to work at own

Assist patient in doing passive

Tasks require energy. Fatigued

Orlea A. Francisco, R.N.

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