NURSING CARE PLAN

Cues Nursing
Diagnosis
Analysis Goal and
Objectives
Nursing
Interventions
Rationale Evaluation
Subjective:
The client
verbalized
Nahihirapan
ako sa
kalagayan ko
kasi hindi ako
makagalaw
ng maayos
Objective:
Difficulty
turning
Limited range
of motion









Actual
Diagnosis:
Impaired physical
mobility r/t
musculoskeletal
impairement as
evidenced by
imposed
immobility by
traction
Fracture is a
break in the
continuity of the
bone.
Immobilization is
needed to correct
the position and
alignment of the
bone.
Immobilization
may be
accomplished by
external and
internal fixation.
Methods of
external fixation
include bandages,
casts, splints, and
traction.Suzanne C,
Smeltzer, RN, EdD,
FAAN, Brenda G. Bare,
RN, MSN Brunner &
Suddarths Medical-
Surgical Nursing 10
th
ed.
Goal: By May 31
2014 the client will
be free of traction
and will be able to
walk at least 20 ft
with the use of the
walker.
Objective: After 8
hours of duty, the
client will:
K: Learn to
correctly
reposition herself
on a regular
schedule.
Learn
active/passive
range of motion
exercises of
unaffected and
affected extremity
Learn diversional
1. Encourage
participation in
diversional activities.
Maintain stimulating
environment, e.g.,
radio, TV,
newspapers,
personal
possessions/pictures,
clock, calendar, visits
from family/friends.

2. Instruct patient
in/assist with
active/passive ROM
exercises of affected
and unaffected
extremities.


3. Encourage use of
1. Provides
opportunity for
release of energy,
refocuses
attention,
enhances patients
sense of self-
control/self-worth,
and aids in
reducing social
isolation.

2. Increases blood
flow to muscles
and bone to
improve muscle
tone, maintain
joint mobility;
prevent atrophy
and calcium
resorption from
disuse
3. Facilitates
Effectiveness:
Was the
client able to
identify and
demonstrate
interventions
that will
relieve
present
condition?
Yes?

No?

Why?

Where the
interventions
enough to


activities
Learn the use of
overhead trapeze
Learn appropriate
foods for faster
healing

S: Demonstrate
and practice
active range of
motion exercises
Demonstrate and
practice the use of
overhead trapeze
A: Encourage
participation in
diversional
activities
Encourage self-
care activities
trapeze




4. Assist
with/encourage self-
care activities (e.g.,
bathing, shaving).


7. Reposition
periodically

8. Provide diet high
in proteins,
carbohydrates,
vitamins, and
minerals

9. Increase the
movement during
hygiene/skin care
and linen
changes; reduces
discomfort of
remaining flat in
bed.
4. Improves
muscle strength
and circulation,
enhances patient
control in situation,
and promotes self-
directed wellness.
7. Prevents skin
complications

8. In the presence
of musculoskeletal
injuries, nutrients
required for
healing are rapidly
depleted
9. Adding bulk to
stool helps
prevent
solve the
clients health
problem?

Yes?

No?

Why?
amount of
roughage/fiber in the
diet.

constipation.