NURSING CARE PLAN

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired physical Trauma At the end 6hrs. of > Determine > To identify After 6hrs. of
mobility related to (Vehicular nurse-patient diagnosis that contributing nurse-patient
“Hindi ko loss of integrity of accident) interaction and contributes to factors interaction and
maigalaw ung bone structures intervention, the immobility. intervention, the
binti ko ”, as (fracture) Fracture of the left patient will: patient has:
verbalized by the leg > note situations > cause it may a.) Verbalized
patient a.) Verbalize such as fractures restrict movement understandin
bleeding from understanding g of the
Objective: damaged ends of of the situation > determine the > to assess situation and
bone and and individual degree of immobility functional mobility individual
>limited range of surrounding tissue treatment in relation to treatment
motion regimen and suggested scale regimen and
stimulates safety safety
>slowed inflammatory measures. > determine > to assess measures.
movement response b.) Participate in presence of presence of b.) Participated
ADLs and complications complications in ADLs and
>limited ability to increased capillary desired related to immobility desired
perform gross permeability activities (pneumonia, activities
and fine motor c.) Maintain elimination c.) Maintained
fluid and cellular position of problems,decubitus) position of
> with cast on left exudation function and function and
leg skin integrity > Assist client > to promote skin integrity
pain as evidenced reposition self on a optimum level of as evidenced
>Functional by absence of regular schedule. function and by absence
Level: 3 impaired physical decubitus prevent of decubitus
mobility ulcers complications ulcers
d.) Maintain and d.) Maintained
increase > Support affected > to maintain and
strength and body part using position and increased
function of pillows. function and strength and
affected part. reduce risk of function of
pressure ulcers. affected part.

> Encourage > It promote well-

adequate intake of being and
fluids/nutritious maximizes energy
foods production
 ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Risk for infection Trauma At the end of the >Note risk factor for >To assess After 6hr nurse-
related to wound (Vehicular 6hr nurse-patient occurrence of infection causative/ patient interaction
secondary to accident) interaction and contributing and intervention
fracture intervention the factors the patient has :
Fracture of the left patient will:
leg >Observe for localized >To assess for a.) identified
a.) Identify signs of infection infected sites interventions to
Objective: bleeding from interventions to . prevent/reduce
(+) presence of damaged ends of prevent/reduce >Stress proper hand- >A first line risk of infection
wound bone and risk of infection hygiene by all defense against
surrounding tissue caregivers bet. healthcare- b.) Achieved
V/S taken as b.) Achieve timely Therapies/clients. associated timely wound
follows: broken skin wound healing; infections healing; be
Temp: (wound) be free of free of purulent
RR: purulent >Recommend routine >To reduce drainage or
PR: Risk for infection drainage or or body shower/scrub bacterial erythema;
BP: erythema; when indicated colonization
c.) Been afebrile
c.) Be afebrile as >Change surgical or >To prevent as evidenced
evidenced by other wound infection by the normal
the normal dressings, as V/S.
V/S. indicated, using
proper technique for
changing or disposing
of contaminated
materials

>Review individual >To promote

nutritional needs, wellness.