Benguet State University

COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
Constipation related to lack of physical Short term: After 24 hours of nursing Long term: After two months of nursing
September activity interventions, patient will be relieved from interventions, patient will maintain a
29, 2016 discomfort of constipation. regular pattern of elimination.

INDIVIDUAL IMPLEMENTATION
PROBLEMS
(CUES)
APPROACHES RATIONALE
Subjective: 1. Check on the usual pattern of elimination, 1. It is very crucial to carefully know what is normal for each patient. The normal
Duwa nga including frequency and consistency of stool. frequency of stool passage ranges from twice daily to once every third or fourth
domingo en nga 2. Assess the patients activity level. day. Dry and hard feces are common characteristics of constipation.
han nga 3. Determine the patients need for privacy for 2. Sedentary lifestyle such as sitting all day, lack of exercise, prolonged bed rest and
elimination. inactivity contribute to constipation.
tinmakki, as 3. Defecating is a private thing. Most patients may have a hard time defecating
verbalized by 4. Consider the degree to which the patient away from the sense of privacy in their home.
brother. responds to the urge to defecate. 4. Ignoring the urge to defecate eventually leads to chronic constipation because
the rectum no longer senses or responds to the presence of stool. The longer the
Objective : 5. Assist patient to take at least 20 g of dietary stool stays in the rectum, the drier and harder it becomes. This will make the
Distended fiber (e.g., raw fruits, fresh vegetable, whole stool difficult to pass.
abdomen grains) per day. 5. Fiber adds bulk to the stool and makes defecation easier because it passes
Hypoactive bowel 6. Digitally eliminate the fecal impaction, if through the intestine essentially unchanged.
sounds necessary. 6. Stool that remains in the rectum for long periods becomes dry and hard;
7. Advise the patient and his family members debilitated patients, especially older patients, may not be able to pass these
to decrease fiber and increase fluid intake in stools without manual assistance.
the patients diet once he is able to orally 7. An individual needs only about 25 grams to 30 grams of fiber and 2-3 liters of
ingest food. water every day to soften the stool and encourage proper bowel function.

ACTUAL OUTCOME DATE AND TIME RECEIVED

September 29, 2016
7 am

NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
SUBMITTED BY: Group Y Level III SUBMITTED TO:
22
 Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
Risk for Aspiration related to presence of Short term: After 8 hours of Long term: After 1 day patient will digest
September tracheostomy intervention, the patient will not food by gastric feeding without aspiration.
29, 2016
develop any of the risk of
complication.

INDIVIDUAL PROBLEMS IMPLEMENTATION

APPROACHES RATIONALE
1. Monitor respiratory rate, depth, and effort. 1. Signs of aspiration should be detected as soon as possible to
Subjective: Note any signs of aspiration such as prevent further aspiration and to initiate treatment that can
dyspnea, cough, cyanosis, wheezing, or be lifesaving.
idjay tube ladta ti fever. 2. A client with aspiration needs immediate suctioning and will
pang idalanan ti 2. Have suction machine available when
need further lifesaving interventions such as intubation
kanenna ken hannga feeding client. If aspiration does occur,
3. Decreased or absent bowel sounds can indicate an ileus with
ma-suction unay suction immediately.
3. Listen to bowel sounds every hour, noting possible vomiting and aspiration; increased high-pitched
tadtan ,as verbalized if they are decreased, absent, or bowel sounds can indicate mechanical bowel obstruction with
by the watcher. hyperactive. possible vomiting and aspiration.
4. Note new onset of abdominal distention or 4. Abdominal distention or rigidity can be associated with
Objective: increased rigidity of abdomen. paralytic or mechanical obstruction and an increased
5. Keep nasogastric tube securely taped. likelihood of vomiting and aspiration.
-flat on bed, with
Check to make sure initial feeding tube 5. Auscultation involves instilling air into the feeding tube with a
intact tracheostomy placement by auscultation. syringe while using a stethoscope placed over the stomach
tube. 6. Check for gastric residual every 4 hours
to listen for rushing air determining safe placement of
during continuous feedings or before
-inability to swallow feedings; if residual is (100 ml for feeding tubes.
thus with intact gastrostomy feedings or (200 ml for 6. Increased intragastric pressure from retained feeding can
nasogastric tube. nasogastric tube feedings, hold feedings result in regurgitation and aspiration, but holding feeding
following institutional protocol. unnecessarily can also result in an inadequate caloric intake.
ACTUAL OUTCOME DATE AND TIME RECEIVED
Gastric feeding without aspiration and maintains patent airway and clear lung September 29, 2016; 7 am
sound

23
NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
Impaired skin integrity related to pressure Short term: Long term:
September ulcers secondary to prolonged immobility Within 2-3 days of nursing In a month, the occurrence of pressure
29, 2016 interventions, patient will experience ulcers will be avoided.
and unrelieved pressure.
healing of ulcer or reduce size of skin
ulcer.

INDIVIDUAL PROBLEMS (CUES) IMPLEMENTATION

Subjective:
ada ti sugat idjay
duwa nga saka na, as
verbalized by the watcher
Objective:
-flat on bed for more than 2
weeks
-Stage II pressure ulcer
observed on the posterior
ankle of the right lower leg
and at the left ankle;
epidermis damaged and
presents as an abrasion, no
foul odor.
APPROACHES
1. Assess skin color, turgor, sensation, wounds
and observe for changes.
2. Note objective data of pressure ulcers
(stage, length, width, depth, wound bed
appearance, and condition of periulcer
tissue).
3. Keep the area clean and dry by using
nonirritating lines, bed clothes dry and
wrinkled free.
4. Elevate heels off the bed using pillows.
5. Follow body substance isolation
precautions, use clean gloves for wound
care and proper hand washing before and
after wound care.
6. Ensure adequate dietary intake.
7. Prevent the ulcer from being exposed to
urine or feces. Use topical creams.
8. Instruct the watcher not to massage around
the site of skin impairment and over bony
prominences.
RATIONALE
1. Establishes comparative baseline
providing opportunity for timely
intervention.
2. Analyses of the trends in healing are
important step in assessment.
3. To reduce risk of infection.
4. Heel covers do not relieve pressure, but
they can reduce friction.
5. To reduce risk of infection.
6. To prevent malnutrition and delayed
healing.
7. To prevent contamination or spread of
infection.
8. Massaging around the site may lead to
deep tissue trauma.
24
 ACTUAL OUTCOME DATE AND TIME RECEIVED

NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
SUBMITTED BY: Group Y Level III SUBMITTED TO:
Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
September Ineffective Airway Clearance related to Short term:After 24 hours the patient will Long term: After 1-2 days patient wil be fre
29, 2016 presence of endotracheal tube. maintain clear, open airways as evidenced of dyspnea.
by normal breath sounds, normal rate and
depth of respirations.

INDIVIDUAL PROBLEMS IMPLEMENTATION

(CUES)
APPROACHES
Subjective: 1. Assess airway for patency.
2. Assess respirations. Note quality, rate,
Inmado met ti iruruwar pattern, depth, flaring of nostrils,
na nga plema idjay ngiwat dyspnea on exertion, evidence of
na, as verbalized by the splinting, use of accessory muscles, and
position for breathing.
watcher. 3. Auscultate lungs for presence of normal
or adventitious breath sounds
Objective :
4. Note cough for efficacy and productivity.
-increased sputum 5. Note presence of sputum; evaluate its
quality, color, amount, odor, and
production consistency.
6. Submit a sputum specimen for culture
and sensitivity testing, as appropriate.
7. Use pulse oximetry to monitor oxygen
saturation; assess arterial blood gases
(ABGs).
8. Perform tracheal suctioning.
RATIONALE
1. Maintaining patent airway is always the first priority, especially in cases
like trauma, acute neurological decompensation, or cardiac arrest.
2. A change in the usual respiration may mean respiratory compromise. An
increase in respiratory rate and rhythm may be a compensatory
response to airway obstruction.
3. Abnormal breath sounds can be heard as fluid and mucus accumulate.
This may indicate airway is obstructed.
4. Coughing is a mechanism for clearing secretions. An ineffective cough
compromises airway clearance and prevents mucus from being expelled.
Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious
secretions are possible causes of ineffective cough.
5. Unusual appearance of secretions may be a result of infection,
bronchitis, chronic smoking, or other condition. A discolored sputum is a
sign of infection.
6. Labored breathing may be a sign of respiratory infection that needs an
appropriate treatment of antibiotics.
7. Pulse oximetry is used to detect changes in oxygenation. Oxygen
saturation should be maintained at 90% or greater. Alteration in ABGS

25
 9. Teach the patient the proper ways of
coughing and breathing. (e.g., take a
deep breath, hold for 2 seconds, and
cough two or three times in succession).
may result in increased pulmonary secretions and respiratory fatigue.
8. Suctioning is needed when patients are unable to cough out secretions
properly due to weakness, thick mucus plugs, or excessive or tenacious
mucus production.
9. The most convenient way to remove most secretions is coughing. So it is
necessary to assist the patient during this activity. Deep breathing, on
the other hand, promotes oxygenation before controlled coughing.

ACTUAL OUTCOME DATE AND TIME RECEIVED

NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
SUBMITTED BY: Group Y Level III SUBMITTED TO:

Benguet State University

COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
Impaired physical mobility related to Short term: After 1-2 days the patient Long term: After 6-7 days patient has
September verbalizes feeling of increased strength . increase ability to move his upper
29, 2016
neuromuscular/ musculoskeletal
extremities.
impairment

INDIVIDUAL PROBLEMS IMPLEMENTATION

(CUES)
APPROACHES RATIONALE

26

Subjective:
Maasi ak tani halos 2.
haanen met nga maka-
kuti, as verbalized by the
watcher.
Objective :
- Limited range of motion
- Limited ability to
perform gross motor
skills
- Functional level: 3
(requires help from
another person and
device)
NAME OF PATIENT: Patient Y
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50
SEX: Male
SUBMITTED BY: Group Y Level III
1. Evaluate patients ability to perform 1. Restricted movement influences the capacity to perform most
Activities of Daily Living efficiently and activities of daily living. Safety with ambulation is a significant
safely on a daily basis. matter. Determines strengths or insufficiency and may give
Assess the strength to perform ROM to information regarding recovery. This helps out in preference of
all joints. actions since different methods are used for the following: flaccid
3. Assess input and output record and and spastic paralysis.
nutritional pattern. 2. This assessment provides data on extent of any physical problems
4. Assess the patients or caregivers and guides therapy. Testing by a physical therapist may be needed.
understanding of immobility and its 3. Pressure ulcers build up more rapidly in patients with a nutritional
implications. insufficiency.
5. Monitor nutritional needs as they relate 4. The risk for effects of immobility such as muscle weakness, skin
to immobility. breakdown, pneumonia, constipation, thrombophlebitis, and
6. Present a safe environment: bed rails up, depression are also to be considered in patients with temporary
bed in down position, important items immobility.
close by. 5. Good nutrition also gives required energy for participating in an
7. Keep limbs in functional alignment with exercise or rehabilitative activities.
one or more of the following: pillows, 6. These measures promote a safe, secure environment and may
sandbags, wedges, or prefabricated reduce risk for falls.
splints. 7. This avoids footdrop and too much plantar flexion or tightness.
8. Provide foam or flotation mattress, water Maintain feet in dorsiflexed position.
or air mattress or kinetic therapy bed, as 8. These equipment decrease pressure on skin or tissues that can
necessary. damage circulation, potentiating risk of tissue ischemia or
breakdown and decubitus formation.
ACTUAL OUTCOME DATE AND TIME RECEIVED
ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
DATE ADMITTED: March 10,2016
SUBMITTED TO:
27