Nursing Care Plan

Date: Time: Shift:

Assessment Diagnosis Planning Intervention Evaluation

Impaired physical mobilty
related to pain, inability to
move freely.
-Limitation in
independent, purposeful
physical movement of the
body of one or more
extremities.
Nurse’s Pocket Guide,
Marilynn E. Doenges,
Mary Frances Moorhouse,
Alice C. Murr, 2017
(pages 542-547).
At the end of our 8 hours
span of duty our patient
will be able to:
1.Verbalize understanding
of situation and individual
treatment regimen and
safety measures.
2.Maintain or increase
strength and function of
affected and/or
compensatory body part.
1. Assessed clients
developmental level,
motor skills, ease and
capability of movement,
posture and gait.
Rationale: to determine
presence of characteristics
of clients unique
impairment and to guide
choice of interventions.
2. Noted emotional/
behavioral responses to
problems of immobility.
Rationale: Feelings of
frustration or
powerlessness may
impede attainment of
goals.
3. Assessed degree of
pain, listening to clients
description about manner
in which pain limits
mobility.

Rationale: To determine if
pain management can
improve mobility.

4. Assisted patient to do
active ROM exercise on
the head.

Rationale: To improve
muscle strength and
mobility.

5. Assisted treatment of
underlying condition
causing pain and/ or
dysfunction.

Rationale: To maximize
the poteential for mobility
and function.

6. Administered analgesics
prescribed by the
physician.

Rationale: In order for the

muscle to be more relax
and relieves the pain.

7. Consult with physical or

occupational therapist as
indicated.

Rationale: To develop
individual exercise or
mobility program.
 Nursing Care Plan

Date: Time: shift:

Assessment Diagnosis Planning Intervention Evaluation

Subjective Cue Acute pain related to After 8 hours of nursing 1. Instructed client to
physical injury agent; intervention the patient report any
abscess as manifested by will be able to: improvement/exacerbation
facial grimace in pain experience.

1. Verbalize reduction/
relief of pain. Rationale: Unrelieved pain
can create other problems
-An unpleasant sensory
such as anger, anxiety,
and emotional experience
2. Verbalize non- immobility, respiratory
associated with actual or
pharmacological methods problems, and delay in
potential tissue damage;
that provide pain healing.
sudden or slow onset of
any intensity from mild to
severe with an anticipated
3.Demostrate use of 2. Encouraged
or predictable end.
relaxation skills and verbalization of feelings
diversional activities.. about the pain.
Nurse’s Pocket Guide,
Marilynn E. Doenges,
Rationale: Only the client
Mary Frances Moorhouse,
can judge the level and
Alice C. Murr, 2017
distress in pain; pain
(pages 600-605).
management should be a
team approach that
includes the client.

3. Provided comfort
measures such as assistive
pillow that is placed at the
back of the patient .

Rationale: To provide non-

pharmacologic pain
management.

4. Encouraged significant
others to perform touch
therapy.
Rationale: The human
body is believe to have
energy fields that express
aberrant patterns when
body systems are insulted.
Therapeutic touch is
thaught to re-allign
aberrant fields.

5. Encouraged and assisted

clients to do deep
breathing exercises.

Rationale: Deep breathing

for relaxation is easy to
learn and contributes to
pain relief and/or
reduction by reducing
muscle tension and
anxiety.

6. Provided psychological
support/motivation
Rationale: If the client is
ill, ascertain the
motivation for returning to
an optimal level of
wellness.

7. Administered analgesic
as prescribed.

Rationale: Necessary for

treatment of the
underlying cause. To
maintain acceptable level
of pain.
 Nursing Care Plan

Date: Time: Shift:

Assessment Diagnosis Planning Intervention Evaluation

Readiness for enhanced At the end of our 7-3 shift 1. Ascertain the client’s
Health Management. our patient will be able to beliefs about health and
to : his ability to maintain
health.
A pattern of regulating an
integrating into daily 1. Assume responsibility
living a therapeutic for managing treatment Rationale: Belief in the
regimen for treatment of regimen. ability to accomplish
illness and its sequelae, desired actions is
which can be predictive of performance.
strengthened. 2. Identify and use
additional resources as
appropriate. 2. DetermineD the Clients
current health status and
perception of possible
Nurse’s Pocket Guide,
3. Remain free of threats to health.
Marilynn E. Doenges,
preventable complications,
Mary Frances Moorhouse,
progression of illness and
Alice C. Murr, 2017
sequelae. 3. Determined the
(Pages 410-413).
influence of cultural
beliefs on the client/
caregiver participation in
the regimen.
Rationale: This factors
influence the way people
view health issues and
management.

4. Acknowledged
individual efforts and
capabilities to reinforce
movement toward
attainment of desired
outcomes.

Rationale: This provides

positive reinforcement
encouraging continued
progress towards desired
goals.

5. Incorporated the clients

cultural values or religious
beliefs that support
attainment of health goals.
Rationale: Person has
different perception in
dealing thier health.
 Nursing Care Plan

Date: Time: Shift:

Assessment Diagnosis Planning Intervention Evaluation

Subjective cue:
“dako kaayo akong samad
sa likod sa akong liog
maam” as verbalized by
the patient
Objective:
•D i s r u p t i o n o f s k i n
surface at posterior
neck
•W o u n d i s 6 m m i n
diameter.
•Localized erythema
•Purulent discharge
•(+) pruritus on thesite
of the wound
Impaired skin integrity At the end of our 7-3 shift 1.Identify underlying
related to inflammatory our patient will be able to : condition or pathology
response secondary to involved; penetrating
infection. wound.
1.Identify individuals risk
factors.
- Altered epidermis and/or Rationale: to identify
dermis. what are the underlying
2.Participate in prevention condition that may impair
measures and treatment healing.
Nurse’s Pocket Guide, program.
Marilynn E. Doenges,
Mary Frances Moorhouse, 2.Assessed skin, noted
Alice C. Murr, color, turgor and sensation
2017,(pages 783-791).
Rationale: Establish
comparative baseline
providing opportunity for
timely intervention.
3.Assessed Vital Signs
specially body temperature
Rationale: To know any
changes in patients
condition.

4.Demonstrated good skin

hygiene; wash thoroughly
and pat dry carefully.

Rationale: Maintaining
clean and dry skin provide
a barrier to infection.
Patting skin dry instead of
rubbing reduces risk of
dermal trauma to fragile
skin.

5.Instructed family to
maintain clean dry clothes
preferably cotton fabric
(any tshirt).
Rationale: Skin friction
caused by stiff or rough
clothes leads to irritation
of fragile skin and
increases risk for
infection,

6.Demonstrated to the
family members on how to
make a guava decoction to
apply to the wound as
alternative disinfectant.

Rationale: Providing the

family with alternative
solution assists them in
optimal healing with less
expensive resources.

7.Instructed the family to

clip and file nails
regularly.
Rationale: long and rough
nails increases risk of skin
damage if use to scratch.

8.