NURSING CARE PLAN

ASSESSMENT NURSING INTERFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

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

ulcers fluids/nutritious ulcers

d) Maintain and d) Maintained
foods
increase and

strength and increased

function of strength and

affected part. function of

affected part.
ASSESSMENT NURSING INTERFERENCE PLANNING INTERVBNTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Trauma >Note risk factor
Objective: Risk for infection (Vehicular At the end of the for >To assess After 6hr nurse-
(+) presence of accident) occurrence of
wound related to wound Fracture of the left 6hr nurse-patient infection causative/ patient interaction
V/S taken as leg >Observe for
follows: secondary interaction and localized contributing and intervention
Temp: to bleeding from signs of infection
fracture intervention the .>Stress proper factors the patient has :
damaged ends of hand- >To assess for a) identified
patient will: infected sites
RR:
bone and a)Identify hygiene by all >A first line interventions to

surrounding tissue interventions to caregivers bet. defense against prevent/reduce

PR:
broken skin
(wound) prevent/reduce Therapies/clients. healthcare- risk of infection
Risk for infection b)Achieved
BP: risk of infection associated
>Recommend
b)Achieve timely timely wound
routine or body infections
wound healing; healing; be
shower/scrub >To reduce
be free of free of purulent
when indicated bacterial
purulent drainage or
drainage or >Change surgical colonization erythema;
erythema; >To prevent c)Been afebrile
c)Be afebrile as or infection
>To promote as evidenced
evidenced by other wound wellness.
by the normal
the normal dressings, as
V/S.
V/S. indicated, using

proper technique

for

changing or

disposing

of contaminated

materials
>Review
individual
nutritional needs,