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ASSESSMENT

Subjective:
I cannot move
my left leg
Objective:
(+) Facial
Grimace
Limited range
of motion
Slowed
movement
Limited ability
to p e r f o r m
g r o s s and fine
motor
With cast on left
leg
Postural
Instability

NURSING
DIAGNOSIS
Impaired
physical
mobility
related to loss
of integrity
of b o n e
str u ctu re s

PLANNING

INTERVENTION

To m a i n t a i n
a n d increase
strength and
function
of affected part

1. Note situations such


as fractures

Cause it may restrict


movement

2. Determine the
degree of immobility in
relation to suggested
scale

To assess functional
mobility

3.Determine presence
of complications
related to immobility
(pneumonia,
elimination problems,
decubitus)

To assess presence
of complications

4. Assist client
reposition self on a
regular schedule
5.Encourage adequate
intake
of fluids/nutritious
foods
6.Support affected
part using pilow

NURSING CARE PLAN FOR FRACTURE

RATIONALE

To promote optimum
level of function and
prevent complications
It promotes well-being
and maximizes energy
production
To maintain position
and function and
reduce risk of pressure
ulcers

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Participation i
n ADLs and desired
activities
Maintained position
of function and skin
integrity as
evidenced by
absence of
decubitus ulcer
M a i n t a i n e d and
Increased strength
and
function of affected
part

ASSESSMEN
T

NURSING
DIAGNOSIS

Subjective:

Acute Pain related


to movement of
bone fragments
and injury to the
soft tissue

I have pain on
my left leg
with pain
scale of 7/10

PLANNING

INTERVENTION

To decrease the
level of pain from
pain scale of 7/10
to 2/10

1. Assess presence of
pain or discomfort,
noting location and
characteristics,
including intensity (0
10 scale), relieving and
aggravating factors

Objective:
Incision on the
left ankle
Posterior casts
and bandage
onleft ankle
Restless
Difficutly Turning
(+) Facial
Grimace
BP = 130 /
70mmHg

2. Elevate and support


injured extremity
3. Maintain
immobilization of
affected part by means
of bed rest, cast, splint,
traction as order by the
physician
4.Encourage patient to
discuss problems
related to injury

Pulse:110 bpm
5. Perform and
supervise active and
passive ROM exercises.

6. Provide alternative
comfort
measures (massage,
backrub, position
changes).

RATIONALE
Influences
effectiveness of
interventions. Many
factors, including
level of anxiety,
may affect
perception of pain.
Note: Absence of
pain expression
does not necessarily
mean lack of pain
Promotes venous
return, decreases
edema, and may
reduce pain
Relieves pain and
prevents bone
displacement and
extension of tissue
injury
Helps alleviate
anxiety. Patient may
feel need to relive
the accident
experience
Maintains
strength and mobilit
y of unaffected
muscles and
facilitates resolution
of inflammation in
injured tissues
Improves general
circulation; reduces

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Verbalization that
pain was relieved
from pain scale of
7/10 to 2/10

7. Apply cold or ice


pack first 2472 hr and
as necessary.

Administer analgesics
as ordered

areas of local
pressure and
muscle fatigue
Reduces edema and
hematoma
formation,
decreases pain
sensation. Note:
Length of
application depends
on degree of patient
comfort and as long
as the skin is
carefully protected.
Given to reduce
pain or muscle
spasms.

ASSESSMEN
T

NURSING
DIAGNOSIS
Risk for infection
related to wound
s e c o n d a r y
t o fracture

PLANNING

INTERVENTION

To achieve timely
1. Note risk factor
wound healing; be for occurrence of
infection
free of purulent
drainage
or erythema
2. Observe for localized
signs of infection

RATIONALE
To assess
causative/contributi
ng factors
To assess for infected
sites

3. Stress proper handhygiene by all


caregivers between
Therapies /clients

A first line defense


against healthcareassociated
infections

4.Change surgical
or other wound
dressings, as indicated,
using proper technique
for changing or
disposing of
contaminated materials

To prevent infection

To promote wellness
5.Review individual
nutritional needs

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
No signs of infection
noted on the site
and achieved timely
wound healing; no
presence of purulent
discharge or erythema

NURSING CARE PLAN FOR RHEUMATOID ARTHRITIS

ASSESSMEN
T

NURSING
DIAGNOSIS

Subjective:

Disturbed Body
Image Related to
changes in ability
to perform usual
tasks

I don t want
to go outside
the house
because of
my condition
Objective:
Crying
Expressions of
helplessness

PLANNING
To verbalize
increased
confidence in
ability to deal
with illness,
changes in
lifestyle, and
possible
limitations.

INTERVENTION

RATIONALE

Encourage
verbalization about
concerns of disease
process, future
expectations.

Provides
opportunity to
identify fears and
misconceptions and
deal with them
directly.

Encouraged a balanced
diet, but make sure the
patient understands
that special diets wont
cure RA. Stress the
need for weight control.

Obesity adds further


stress to joints.

Ascertain how patient


views self in usual
lifestyle functioning,
including sexual
aspects.

Acknowledge and
accept feelings of grief,
hostility, dependency.

Note withdrawn
behavior, use of denial,
or over concern with
body changes.

Identifying how
illness affects
perception of self
and interactions
with others will
determine need for
further intervention
and counseling.
Constant pain is
wearing, and
feelings of anger
and hostility are
common.
Acceptance
provides feedback
that feelings are
normal.
May suggest
emotional

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Verbalization in
increase in
confidence in ability
to deal with illness
and changes in
lifestyle

Set limits on
maladaptive behavior.
Assist patient to
identify positive
behaviors that will aid
in coping.
Assist with grooming
needs as necessary.
Give positive
reinforcement for
accomplishments.

exhaustion or
maladaptive coping
methods, requiring
more in-depth
intervention or
psychological
support.
Helps patient
maintain selfcontrol, which
enhances selfesteem.
Maintaining
appearance
enhances selfimage.
Allows patient to
feel good about self.
Reinforces positive
behavior. Enhances
self-confidence.

ASSESSMENT
Subjective:
I cannot move
my left hand
because of
stiffness

NURSING
DIAGNOSIS
Impaired physical
mobility as
evidence by joint
stiffness and pain
risk for arthritis

PLANNING

INTERVENTION

To display no
signs of stiff
joints and sore
joints

1. Perform physical
assessment on vital
signs
2. Ask the patient to
stand and record the
findings

Objective:
Fatigue,
malaise, sore
and stiff joints
Inability to
move
extremities
Losing of
weight

3. Educate patient to
drink plenty of Milk
4.encourage to
increase Fluid intake
5. Administer
medications for Pain
relief and Fever control.

RATIONALE
To determine the
level of fever.
To document the
patients weight
and compare it to
any old record to
determine if the
patient has indeed
lost weight
Calcium helps
fortify the patients
bones and risk for
osteoporosis.
Fluids can help the
patients fluid
balance.
To control the
patients fever and
pain endured

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Ability to perform
activities of daily
living

ASSESSMENT
Subjective:
I'm having
severe joint
pain
Objective:
Guarding/prote
ctive behavior
Restlessness
facial grimacing

NURSING
DIAGNOSIS
Acute pain
related to
distension of
tissues by
accumulation of
fluid

PLANNING

INTERVENTION

To alleviate pain
from a pain scale
of 7/10 to 2/10
and appear relaxed,
able to sleep/rest
and participate in
activities
appropriately

Investigate reports of
pain, noting location
and intensity(scale of
010). Note
precipitating factors
and nonverbal pain
cues.
Recommend/provide
firm mattress or
bedboard, small pillow.
Elevate linens with bed
cradle as needed.

Irritable
Skin warm to
touch
pain scale of 7
out of 10

Suggest patient
assume position of
comfort while in bed or
sitting in chair. Promote
bedrest as indicated.

RATIONALE
Helpful in
determining pain
management needs
and effectiveness of
program

Soft/sagging
mattress, large
pillows prevent
maintenance of
proper body
alignment, placing
stress on affected
jointsElevation of
bed linens reduces
pressure on
inflamed/painful
joints

Apply ice or cold


packs when indicated

In severe
disease/acute
exacerbation, total
bedrest may be
necessary (until
objective and
subjective
improvements are
noted) to limit
pain/injury to joint.

Administer medications
as indicated

Cold may relieve


pain and swelling
during acute
episodes.

Salicylates, e.g.,
aspirin (ASA) (Acuprin,
Ecotrin, ZORprin);

Provides sustained
heat to reduce pain

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Verbalization of
relief of pain from
pain scale of 7/10 to
2/10 and able to
demonstrate relaxed
body posture and be
able to sleep/rest
appropriately

and improve ROM of


affected joints

ASSESSMENT
Subjective:
I cannot stand
up because of
weakness all
over my body
Objective:
With limited
ROM
Unable to
ambulate
Body weakness
noted
Unable to flex

NURSING
DIAGNOSIS
Activity
intolerance
related to
generalized
weakness

PLANNING
To increase in
activity tolerance

INTERVENTION

RATIONALE

1.Assess presence of
factors contributing to
fatigue

To assess factors
affecting current
situation

2.Assess if assistance is
needed from another
person

To prevent injury to
patient

3.Encourage active
ROM exercises
4. Note patients report
of weakness, fatigue,
pain and any difficulty
of accomplishing task
5. Monitor vital signs

To maintain muscle
strength and joint
range of motion
Symptoms may be
result or contribute
to intolerance of
activity
To baseline data and
to assist patient to

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:

Patient was able to


increase activity
tolerance but still
needs assistance
when doing a
certain task

and extend
knees freely
Decreased
lower extremity
strength

6.assess nutritional
status
7.Ascertain ability to
stand and move about
and degree of
assistance necessary

8. Assist with activities


and provide/monitor
clients use of assistive
devices such as
crutches, walker, or
wheelchair
9. Promote wellness
- Instruct client/ SO
in monitoring
response to activity
10. Assist patient in
learning and
demonstrating
appropriate safety
measures
Encourage patient to
maintain positive
attitude

deal with
contributing factors
and manage
activities within
individual limits.
Adequate energy
reserves are required
for activity
To determine current
status and needs
associated with
participation in
desired activities
To protect patient
from injury

To indicate the need


to alter activity level

To prevent injuries

To enhance sense of
well-being

NURSING CARE PLAN FOR AMPUTATION


ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:
I cannot walk
because I dont
have legs
anymore
Objective:
amputated
lower
extremities
Left limb- AKA
Right limb-BKA

Impaired physical
mobility r/t loss
of limbs

To independently
perform activities
tolerated by his
present condition
and demonstrate
optimal
independence in
the use of
adaptive device
(wheelchair) to
increase mobility

1. Assess for
impediments to
mobility such as
neuromuscular
impairment, medical
restrictions, prolonged
bed rest, limited
strength, or amputation
of extremities
2. Assess patients
knowledge of
immobility and its
implications

use of
wheelchair
limited range of
motion
slouched
posture
difficulty in
ambulation

3.Evaluate the safety of


the immediate
environment

slowed
movement

4. Encourage and
facilitate ambulation
and other ADLs when
possible. Assisted with
each position changes
such as: sitting in chair
and ambulation.

Identifying the
specific cause
guides design of
optimal treatment
plan

Patients with
mobility deficits are
at risk for effects of
immobility such as
skin breakdown,
muscle weakness,
thrombophlebitis,
constipation,
pneumonia, and
depression

To promote client
safety Obstacles
such as throw rugs
can further impede
ones ability to
ambulate safely.

The longer the


patient remains
immobile the
greater the level of
debilitation that will
occur.

After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Patient was able to
perform
independently some
of the activities
tolerated by his
condition such as
dressing, grooming,
and feeding.

5. Facilitate transfer
training by using
appropriate assistance
of persons or devices
when transferring
patients to bed, chair,
or stretcher.

Proper use of
wheelchairs, canes,
transfer bars, and
other assistance

6. Routinely assess the


clients sitting posture
and help reposition him
into sound alignment as
needed.

Can promote
activity and reduce
danger of falls. This
indirectly improves
posture

7. Remind client to
avoid putting pressure
on their elbows

Arms are
overworked during
propulsion,
transfers,
repositioning, upper
dressing, and thus
they are at risk for
painful syndromes.

8. Encourage client to
perform passive or
active assistive ROM
exercises to all
extremities such as
upper extremity and
neck flexibility once a
day, every day or as
tolerated.

The purpose of this


flexibility program is
to stretch (lengthen)
the muscles in the
upper body that are
tight (shortened).
Exercise promotes
increased venous
return, prevents
stiffness, and
maintains muscle
strength and
endurance.

ASSESSMENT
Subjective:
I am afraid of
what will
happen to my
condition
Objective:
Crying
Expressions of
helplessness

NURSING
DIAGNOSIS
Anxiety related
to unknown
outcome of
disease

PLANNING

INTERVENTION

To have reduction
in anxiety as
evidenced by
verbalizations of
understanding
regarding illness
and acceptance
of possible
outcomes of
disease

1. Assess patients level


of anxiety

2. Assess blood
pressure, heart rate,
and respiratory rate.
3. Determine how
patient copes with
anxiety.

Increase in BP160/100
RR-36 cpm
Restlessness

4. Acknowledge
awareness of patients
anxiety.

5. Reassure the patient


that he/she has
someone or somebody
to depend on.
Maintain a calm
manner while
interacting with client.
6. Use simple language
and brief statements
when instructing
patient about self-care

RATIONALE
Mild anxiety
enhances the
patients awareness
and ability to
identify and solve
problems
These usually
increase during
anxiety
Interviewing and
assessing client
helps determine the
effectiveness of
coping strategies
currently used by
the patient.
Because a cause for
anxiety cannot
always be identified.
Acknowledgement
of the patients
feelings validates
the feelings and
communicates
acceptance of those
feelings.
Avoid false
reassurances. To
allow patient to
accept and prepare
for the possible
outcome of disease.
The presence of a
trusted person may

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Verbalization of
understanding
regarding illness,
acceptance of
possible outcomes
of disease and
positive

measures or about
diagnostic procedures
and medical
interventions.

NURSING CARE PLAN FOR ORIF

be helpful during
this period

ASSESSMENT
Subjective:
I have pain on
my operative
site
Pain scale 8/10
Objective:
Pt grimaces
during any kind
of motion or
movement of
his left lower
extremity

NURSING
DIAGNOSIS
Acute pain
related to ORIF
of left femur

PLANNING

INTERVENTION

To decrease the
level of pain from
8/10 to 2/10 and
perform passive
range of motion
exercises by the
end of this shift

1. Assess the pts pain


by using the 10 point
pain rating scale q4 hrs
or PRN

Single- item ratings


of pain intensity are
valid and reliable as
measures of pain
intensity

After 12 hours of
nursing
intervention, goal
was met as
manifested by:

2. Perform and
supervise active and
passive ROM exercises.

Maintains
strength and mobilit
y of unaffected
muscles and
facilitates resolution
of inflammation in
injured tissues

Patient able to fully


complete passive
range of motion
exercises with
assistance from the
staff by the end of
this shift. Patients
level of pain
decreased from 8/10
to 2/10

3. Maintain
immobilization of
affected part by means
of bed rest

Swelling noted
BP:130/70
Pts ORIF
surgery

4. Encourage to do
deep breathing exercise
5. Administer analgesic
as ordered before any
acitivty

RATIONALE

Relieves pain and


prevents bone
displacement and
extension of tissue
injury
To lessen the pain
and to relax
Pain limits mobility
and is often
exacerbated by
movement

6. Monitor I & O
To evaluate
accurate fluid status

EVALUATION

ASSESSMENT

NURSING
DIAGNOSIS
Risk for infection
related to
postoperative
incision

PLANNING
To be free from any
signs and symptoms
related to infection

INTERVENTION

RATIONALE

EVALUATION

1. Note risk factors


for occurrence of
infection in the incision

To help the
patientidentify the
presentrisk factors
that mayadd up to
the infection

After 12 hours of
nursing
intervention, goal
was met as
manifested by:

2.Observe for localized


sign of infection at
insertion sites of
invasive lines,surgical
incisions or wounds

To evaluate if the
character, presence
and condition of
the present
infection

No signs of infection
noted

3. Make health
teachings especially in
identification
of environmental
risk factors that could
add up on infection

To help the client


modify/change/avoi
d some of the
environmental
factors present
which could reduce
the incidence
of infection.

4 . A d m i n i s t e r ant
ibiotics aso rdered by
the physician

Antibiotics will help


kill and stop
the proliferation and
growth of the
bacteria which could
cause infection

ASSESSMENT
Subjective:
Im afraid of
what will
happen to my
condition
Objective:
Frequent asking
of condition
Restlessness
Apprehension
Fatigue
Cold clammy
skin
Palpitation
Limitation to
participation in
activities
Night sweats

NURSING
DIAGNOSIS
Fear/anxiety
related to
situational crisis
as evidenced by
apprehension
and restlessness

PLANNING
To be able to
appear relaxed
and report
anxiety is reduced
to a manageable
level use
of effective
coping
mechanism and
active
participation in
treatment
regimen

INTERVENTION
1. Determine what the
doctor has told client
and what conclusion
client has reached
2. Encourage client to
share thoughts and
feelings

3. Provide open
environment in which
client feels safe to
discuss feelings or to
refrain from talking
4.Maintain frequent
contact with client, talk
w/and touch client, as
appropriate

5. Permit expressions
of anger, fear, and
despair w/o
confrontation
6. Explain client the
recommended
Treatment, its purpose,
and potential sideeffects.

RATIONALE
Clarifies clients
information

Provides
opportunity to
examine realistic
fears and
misconceptions
about diagnosis
Provides assurance
client is not alone or
rejected

Acceptance
of feelings allows
theclient to begin
todeal w/ situation

Maybe useful in
brief times to help
handle feelings
of anxiety

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by:
Patient was able to
appear relaxed and
report anxiety is
reduced to a
manageable level

ASSESSMENT
Subjective:
Objective:

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION
After 12 hours of
nursing
intervention, goal
was met as
manifested by: