NURSING CARE PLAN

CUENCO, NICOLE JANE Z. BSN-NU1 GROUP:A1

ASSESMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

RATIONALE
SUBJECTIVE Impaired Impaired Short term Independent (5): After 1 weeks of
CUES: physical physical outcome: *Assess patient’s *Identifies nursing
mobility may be mobility related After 2 days of functional abilityproblems and intervention the
“Lagi ng helps to
related to pain to pain as nursing for mobility and client is able to
sumasakit ang and evidence by intervention the note changes. establish a plan demonstrate
mga paa ko at musculoskeletal limited range of client will able of care. the range of
likod ko noong impairment, motion and to: *Provide range of *Helps to motion exercise
nadapa ako sa possibility musculoskeletal *verbalize motion exercises prevent joint and other
hagdan. At evidenced by impairment. understanding every shift. contractures Individual
limited range of of situation and Encourage active and muscle treatment
nahihirapan atrophy.
motion, Reference: individual range of motion regimen and
ako mag lakad. reluctance to Nursing treatment exercises. safety measures
“ as verbalized attempt Diagnosis regimen and Independently.
by the patient movement, Manual: safety measures *Provide *Help client
expressed fear Planning, Independently. accurate identify what is
OBJECTIVE of reinjury and Individualizing, *And able to information reality base.
imposed and enhance self- about the
CUES: *Prevents
restriction or Documenting concept and situation
*Temperature:
limitations. Client Care 5th sense of *Instruct family complications of
36.3 C
Edition By independence. regarding ROM immobility and
*PR: 86bpm
Marilynn E exercises, knowledge
*RR: 18bpm
Doenges, Mary methods of assists family
*BP:110/60mmHg
Frances transferring members to be
*Limited range of
Moorhouse, patients from better prepared
motion
Alice C Murr bed to for home care.
wheelchair, and
Long term turning at routine *Prevents
outcome: intervals. musculoskeletal
After 1- 2 *Apply deformities.
weeks of trochanter rolls
nursing and/or pillows to
intervention the maintain joint
client will able alignment.
to: *To permit
* demonstrate Collaborative(2): maximal effort
the range of * Administer and
motion exercise medications prior involvement in
* to maintain or to activity is activity.
increase needed for pain
strength and relief.
function of * Promotes
affected and * Encourage well-being and
compensatory adequate intake maximizes
body part of fluids and energy
nutritious foods. production