COLLEGE OF NURSING

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S – “Sobrang sakit ng Acute pain r/t muscle After 3 hours of nursing Independent After 3 hours of nursing
balakang ko!” as verbalized spasm, edema and injury to intervention the pt will be > Assess and record the pt’s level > For baseline data and to intervention goal was fully met
by the pt the soft tissue able to: of pain determine effectiveness of aeb:
interventions
O– > display relaxed manner > Position pt to a comfortable > Alignment of body > display of relaxed manner
> facial grimace > verbalize minimal pain position facilitates comfort; > pain level of 3
> guarding behavior (pain level of 2-3) positioning for function > demonstration of relaxation
> pain level of 4 out of 10 > demonstrate use of diminishes stress on skills and diversional activities
relaxation skills and musculoskeletal system
V/S – diversional activities > Maintain immobilization of > Immobilization relieves After 6 hours of nursing
T: 37 affected part using bed rest, cast, pain and prevents bone intervention the goal was partially
BP: 120/90 After 6 hours of nursing splint displacement and extension met aeb:
HR: 120 intervention the pt will be of tissue injury
RR: 22 able to: > Handle the affected extremity > Adequate support > pain scale of 2
gently, supporting it with hands diminishes soft tissue
> verbalize relief of pain or pillow tension
(pain scale of 0-1) > Perform and supervise active > Maintains strength and
and passive ROM exercises mobility of unaffected
muscles and facilitates
resolution of inflammation
in injured tissues
> Provide alternative comfort > Improves general
measures such as massage, circulation; reduces areas of
backrub, position changes local pressure and muscle
fatigue
> Identify diversional activities > It prevents boredom,
appropriate for patient age, reduces muscle tension, and
physical abilities, and personal can increase muscle
preferences strength; it may enhance
coping abilities
> Apply cold or ice pack first 24– > Reduces edema and
72 hr and as necessary hematoma formation
decreases pain sensation
> Assist with frequent changes in > Change of position
position relieves pressure and
associated discomfort

Dependent
> Apply Buck's traction if > Immobilizes fracture to
Submitted by: Submitted to:

GROUP 1 Ms. Myra Hasim

Student Nurse Clinical Instructor
 prescribed decrease pain, muscle
spasm, and external rotation
of hip
> Administer medications as
prescribed:

– analgesics To reduce pain

– muscle relaxants To reduce muscle spasms

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Submitted by: Submitted to:

GROUP 1 Ms. Myra Hasim

Student Nurse Clinical Instructor
S – “Nahihirapan akong Impaired physical mobility After 3 hours of nursing Independent After 3 hours of nursing
gumalaw sa sobrang sakit ng r/t pain or discomfort due to intervention pt will be able > Maintain neutral positioning of > Prevents stress at the site intervention the goal was fully met
balakang ko.” As verbalized fractured hip to: hip of fixation aeb demonstration of
by the pt > Instruct and assist in position > Encourages patient's techniques/behaviors that enable
> demonstrate changes and transfers active participation while resumption of activities
O– techniques/behaviors that preventing stress on hip
> inability/reluctant to move enable resumption of fixation After 48 hours of nursing
> limited ROM activities > Encourage participation in > Provides an opportunity intervention the goal was partially
diversional or recreational to release energy, refocuses met aeb:
After 48 hours of nursing activities. Maintain a stimulating attention, enhances patient’s
intervention pt will be able environment (radio, TV, sense of self-control and > regained mobility
to: newspapers, personal self-worth, and aids in > minimal strength of affected and
possessions, pictures, clock, reducing social isolation compensatory body parts
> regain/maintain mobility calendar, visits from family and
> inc strength/function of friends)
affected and compensatory > Teach patient or assist with > Increases blood flow to
body parts active and passive ROM muscles and bone to
exercises of affected and improve muscle tone,
unaffected extremities preserve joint mobility,
prevent contractures or
atrophy, and calcium
resorption from disuse
> Provide trochanter > Minimizes external
rotation
> Place in supine position > Reduces the risk of
periodically, if possible, when flexion contracture of the
traction is used hip
> Provide and assist with > Early mobility reduces
mobility aids such as complications of bed rest
wheelchairs, walkers, crutches, (phlebitis) and promotes
and canes healing and normalization
of organ function. Learning
the correct way to use aids
is important to maintain
optimal mobility and patient
safety

Dependent
> Administer analgesics as > To relieve pain
prescribed
> Refer to physical therapy > To ensure a consistent
department and more effective regimen

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Submitted by: Submitted to:

GROUP 1 Ms. Myra Hasim

Student Nurse Clinical Instructor
S – “Nahihirapan akong Risk for impaired skin After 2 hours of nursing Independent After 2 hours of nursing
gumalaw sa sobrang sakit ng integrity r/t physical intervention pt will be able > Assess the overall condition of > Assessment of the intervention the goal was fully met
balakang ko.” As verbalized immobilization to demonstrate the skin condition of the skin aeb demonstration of
by the pt behaviors/techniques to provides baseline data for behaviors/techniques to prevent
prevent skin breakdown. possible interventions skin breakdown.
O– > Check on bony prominences
such as the sacrum, trochanters,
scapulae, elbows, heels, inner
After 24 hours of nursing and outer malleolus, inner and After 24 hours of nursing
intervention pt will be free outer knees, back of head intervention the goal was fully met
from wound/lesion. > Evaluate the patient’s strength aeb pt being free from
to move wound/lesion.
> Assess patient’s nutritional > An albumin level less
status, including weight, weight than 2.5 g/dL is a grave
loss, and serum albumin levels sign, indicating severe
protein depletion and at
high-risk of skin breakdown

> Massage skin and bony > Reduces pressure on

prominences. Keep the bed linens susceptible areas and risks
dry and free of wrinkles. Place abrasions and skin
water pads or padding under breakdown
elbows or heels, as indicated
> Reposition frequently > Lessens constant pressure
on the same areas and
minimizes the risk of skin
breakdown

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Submitted by: Submitted to:

GROUP 1 Ms. Myra Hasim

Student Nurse Clinical Instructor
S – “Minsan ay nahihirapan Risk for falls r/t muscle After 3 hours of nursing Independent After 3 hours of nursing
akong tumayo.” As weakness and age-related intervention pt will be able > Place items the patient uses > Items that are too far may intervention the goal was fully met
verbalized by the pt physical changes to: within easy reach, such as call require the patient to reach aeb use of safety measures to
light, urinal, water, and telephone out or ambulate prevent falls and implementation
O– > demonstrate use of safety unnecessarily and can of strategies to increase safety and
measures to prevent falls potentially be a hazard or prevent falls
> implement strategies to contribute to falls
increase safety and prevent > Place beds are at the lowest > Keeping the beds closer After 24 hours of nursing
falls possible position. Set the to the floor reduces the risk intervention the goal was fully met
patient’s sleeping surface as near of falls and serious injury aeb pt not sustaining a fall.
the floor as possible if needed
> Raise side rails on beds, as
After 24 hours of nursing needed
intervention pt will not > Familiarize the patient with the > fall is more likely to be
sustain a fall. layout of the room. Discourage experienced by an
rearranging the furniture in the individual if the
room surrounding is not familiar,
such as furniture and
equipment placement in a
certain area
> Teach pt/SO how to safely > decreases the risk of falls
ambulate, including using safety
measures such as handrails in the
bathroom
> Provide appropriate room > Patients, especially older
lighting, especially at night adults, have reduced visual
capacity. Lighting an
unfamiliar environment
helps increase visibility if
the patient must get up at
night
> Make the primary path clear
and as straight as possible. Avoid
clutter on the floor surface
> Ask the family to stay with the > Helps prevent the patient
patient from accidentally falling

Submitted by: Submitted to:

GROUP 1 Ms. Myra Hasim

Student Nurse Clinical Instructor