NURSING CARE PLAN

Name of Patient: Agency/ Area:

Diagnosis: Rating: ________________

ASSESSMENT
SUBJECTIVE OBJECTIVE
“Nanghina ko palagi tulog asawa ko kasi
nanghihina ako gusto ko lang matulog po Anxious
muna” c body weakness
uneasy
uncomfortable

NURSING DIAGNOSIS
Impaired physical mobility related to physical conditioning

SCIENTIFIC EXPLANATION

Limitation in independent purposeful physical movement of the body or of one or more extremities.
 OBJECTIVES
LONG-TERM SHORT-TERM
Client will mutually defined goals of ambulation at the Client will increase physical activity by and of 8 hour
time of discharge shift

NURSING ACTIONS
INTERVENTIONS RATIONALE
Instruct use of siderails, overhead trapeze, For positional changes
roller pads, walkers or canes

Identify energy conserving techniques for Which limit fatigue and maximizing
ADLS(Activities of daily living) participation

Encourage participation in self care, Enhances self conception and sense of

occupational, divertional or recreational independence
activities

Encouraged clients SO involvement in decision Enhances cimmitment to plan

making as much as possible
 EXPECTED OUTCOME/ EVALUATION

Provide safety measures as indicated by individul situations, including environment management and fall
prevention
Evaluation:
Verbalized understanding of situation and individual treatment regiment and safety measures>

Prepared by: Evaluated by:

__________________________________________
Student Nurse’s Signature over Printed Name Clinical Instructor’s Signature over Printed Name

DATE: ______________ DATE: ______________

Rating: POINTS SCORE

Assessment 25 ________
Nursing Diagnosis 15 ________
Scientific Explanation 10 ________
Objectives 10 ________
Nursing Actions 25 ________
Rationale 10 ________
Expected Outcome/ Evaluation 5 ________

TOTAL: ________

TRANSMUTED GRADE (60% Passing Score): ________