XI.
Nursing Care Plan
ACUTE PAIN – (June 25, 2019)
Assessment Nursing Diagnosis Planning Intervention Rationally Evaluation
Subjective: Acute pain related to tissue trauma as After 3 hours of nursing 1. Assessed patient of To know baseline After 3 hours of nursing
manifested by pain scale 10/10. intervention, patient’s pain characteristic and data, characters, intervention, patient’s pain was
“subrang sakit, dahil will be lessened and duration of pain. duration of pain. lessen from the scale of 10/10
kanilinis lang ng (Pain is a typical sensory experience managed. to 6/10
sugat ko.” that may bed escribed as the 2. Positioned patient in -proper positioning
unpleasant awareness of noxious After 7 hours of nursing comfortable position. helps ease the pain.
Objective: stimulus or bodily harm) intervention, the patient will After 7 hours of nursing
disappear. 3. Taught patient about intervention, patient has
-pain scale: 10/10 deep breathing exercise -it promotes appeared
-facial grimace comfort.
-body weakness
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DISTURBED BODY IMAGE (July 2, 2019)
Assessment Nursing Diagnosis Planning Intervention Rationally Evaluation
Subjective: Disturbed body image Short term: 1) Acknowledged and - Acceptance of this feeling After 2 days of giving
“Ang hirap pala ng ganito, related to femoral surgery After 2 days in giving accept expression of as a normal response to nursing interventions the
feeling ko wala akong (ORIF) as evidenced by nursing intervention, the feelings of frustration, what has occurred patient was able to
silbi” as verbalized by the external traction. patient will be able to grief, hostility. facilitates resolution. It is verbalized acceptance of
patient verbalize acceptance of self not helpful of possible to self and adaptation to
in situation, adaptation to push patient ready to deal altered body image and
Objective: altered body image and with situation. was able verbalized
will be able to verbalize understanding of body
-paralyzed hand understanding of body 2) Provided hope within - Words of encouragement changes.
-feet with traction changes. parameters of individual can support development
-facial grimace situation, do not give false of positive coping After 3 days the patient
-feeling sad, regret Long Term: reassurance. behaviors. was able to recognized and
incorporated body image
After 3 days of giving into self-concept in
nursing intervention, the 3) Encouraged family - maintain open lines of accurate manner without
patient will be able to interaction with each other communication and negating self-esteem and
recognize and incorporate and with rehabilitation provides on ongoing was able to acknowledge
body image change into team. support for patient and self as an individual who
self-concept in accurate family. has responsibility for self
manner without negating
self-esteem, and will be 4) Provided support group - Promotes ventilation of
able to acknowledge self as for So. Give information feelings and allow for more
an individual who has about how so can be helpful responses to
responsibility to self. helpful to patient. patient.
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IMPAIRED PHYSICAL MOBILITY - (July 8, 2019)
Assessment Nursing Diagnosis Planning Intervention Rationally Evaluation
Subjective: Impaired physical mobility related to Short term: 1.Assessed for correct 1.To maintain good After the nursing
musculoskeletal disorder as manifested by After 5hours of nursing position of traction and body alignment when intervention, the patient
“masakit kasi skeletal traction. intervention, the patient alignment of bones. mechanical devices was able to maintain
igalaw ang paa ko, will be able to maintain are used position of function and
hindi pa puweding (Femoral fractures are seen to those people position of function with exerted maximum
e lakad” as who have been involved in motor vehicle maximum mobility within 2. Maintained limbs in 2. This prevents foot mobility within the
verbalized by the crash or who have fallen from high place. the therapeutic limits of functional alignment drop and excessive therapeutic limits of
patient. The patient presents with Skeletal traction is traction. (with pillows, sand bags, plantar flexion traction.
applied directly to the bone to treat fractures etc.). Support feet in
Objective: like the femur by use of metal pin (Steinman Long term: dorsiflexed position. 3. Enhances After 2days of nursing
pin) that is inserted through the bone distal After 2 days of nursing circulation maintains intervention, patient was
-Noted deformity to the fracture. Which supports the affected intervention, patient will 3. Performed passive muscle tone and joint able to integrate some
of thigh due to extremity thus limits patient’s mobility but it do movements with and active ROM mobility and prevents movement with the
fracture also allows for some movement.) maximum mobility within exercises on extremities disuse contractures maximum mobility within
-Limited ROM of the therapeutic limits of and joints, using slow and muscle atrophy. the therapeutic limits of
right lower traction. smooth movements on traction.
extremity the unaffected body 4. To increase
-Presence of parts. patient’s recovery and
restrictive device increase his self-
(skeletal traction) esteem.
-Insertion of
Steinmann pin 4. Allowed patient to
perform tasks at his own
rate. Encourage
independent activity as
able as safe.
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IMPAIRED SKIN INTEGRITY (July 9,2019)
Assessment Nursing Diagnosis Planning Intervention Rationally Evaluation
Subjective: Impaired skin integrity Short term: 1. Assisted skin for color, -stablish comparative After 2 hours of nursing
“parang hindi na related to inflammatory After 2 hours of nursing and turgor, measure baseline data. intervention, patient
gumagaling sugat ko sa response secondary to intervention, patient will wound. verbalized knowledge on
hita ko” as verbalized by infection. have knowledge of proper proper hygiene.
the patient. hygiene. 2. Demonstrated proper -maintaining dry skin is a
(open wound could be the skin hygiene. first barrier for infection. After 2 days of nursing
Objective: portal of entry for Long term: intervention, patient
-prolong immobility microorganisms which After 2 days of nursing -breaking the chain of manifested would healing.
-open wound causes infection to skin) intervention, patient will 3. Instructed family to infection.
-poor circulation manifest wound healing. maintain clean dry cloths,
-poor hygiene cotton.
-pain and itchiness -wrinkles could cause skin
4. Keep bed wrinkle free. irritation and damage.
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