NURSING CARE PLAN

Patients Name: M.J.A. CC: Gunshot Wound Left Lower Quadrant Abdomen Room #: 305
Age: 22 Sex: Male Civil Status: Single Date of Admission: June 10, 2014
Diagnosis: Severe Anemic secondary to massive blood loss secondary to
Gunshot wound Point of Entry: Left lower quadrant abdomen
Point of Exit: Right lower quadrant abdomen

Date & Time Assessment Nursing Diagnosis Planning Nursing Intervention Evaluation
Subjective:
Nahihirapan akong
kumilos, limitado lang
galaw ko kasi masakit
ung sugat sa tiyan ko,
as verbalized by the
patient.

Objective:
>Limited range of motion
>impaired ability to turn
side to side
>Slowed movement
Temp: 37.6c
Hematocrit: 0.39l/l
Hemoglobin: 125g/l
Physiologic Needs
(promote optimal activity;
exercise; rest & sleep)
Impaired Physical
Mobility related to
pain/discomfort.


Rationale:
A limitation in
Independent, purposeful
physical movement of
the body or of one or
more extremities.

Physical agent

damaging the body
tissues and nerve
endings of left lower
quadrant abdomen

Lead to severe
pain/discomfort

Resulting to impairment
of movement

Within 8 hours of
rendering nursing
intervention the patient
will verbalize
understanding of
situation and individual
treatment regimen and
safety measures.
1. Help client achieve
mobility in doing his
activity daily living, if not
contraindicated.
R: the longer the client is
immobile, the longer it
takes to regain strength,
balance, and
coordination.

2.Turn dependent client
from side to side every
2hours, using appropriate
support
R: to prevent tissue
pressures and wicked
away moisture.

3. Instruct client and
caregivers in methods of
moving client relative to
specific situations and
mobility needs.
R:to perform good body
alignment during
repositioning

Goal met, after 8 hours
of duty patient was able
to verbalized
understanding of
situation/risk factors,
individual therapeutic
regimen, and safety
measures as evidenced
by willingness to
participate in
repositioning program.
4. Observe skin for
reddened
areas/shearing. Provide
appropriate pressure
relief.
R: to reduce friction and
maintain safe skin

5. Note
emotional/behavioral
responses to problems of
immobility.
R: feelings of
frustration/powerlessness
may impede attainment
of goal.

6. Instruct in the use of
side rails.
R: for position transfers

7. Ensure call bell is
within reach.
R: to promote safety and
timely response.

8.Observe for and if
possible treat pain before
activity, as needed
R: pain limits mobility and
is often exacerbated by
movement.

Submitted by: Cessa R. Quintana, RN
Date: June 20, 2014