Nursing Care Plan Sample Homework

NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:

“Hindi siya makatagilid sumasakit daw ung bali niya sa may bewang kapag gumagalaw” as verbalized by the sn of the patient.

Objective:

Impaired ability to turn side to side

Impaired ability to move from supine to sitting vise versa.

(+) presence of pelvic fracture

(+) General  weakness

Tremors noted on left arm and hands

Impaired bed mobility related to pain secondary to musculoskeletal impairment.

Trauma

(slipping)

ˇ

bone fracture at pelvic bone

ˇ

Disruptions of periosteum and blood vessels

ˇ

Destruction if tissue

ˇ

Bleeding occurs

ˇ

Pain

ˇ

Impaired bed mobility

After the rotation and nursing intervention the significant other of the patient will:

a. Verbalize understanding of the situation /risk factors, individual therapeutic regimen and safety measures.

b. Demonstrate techniques/ behaviors that will enable safe repositioning

c. Maintain position of function and skin integrity of the patient as evidenced by absence of contractures, foot drop, decubitus, etc.

determine diagnoses that contribute to immobility (e.g. fractures, hemi/para/tetra/quadripegia)

Note individual risk factors and current situation, such pain, age, general weakness, debilitation

Determine perceptual/ cognitive impairment to follow directions

Determine functional  level classification

Note presence of complications related to immobility

Observe skin for reddened areas/shearing. Provide appropriate pressure to relief

Provide regular skin care if appropriate

Assist with activities of hygiene, toileting, feeding, as indicated.

Involve client S/O in determining activity schedule

To identify causative/ contributing factors.

To assess patients functional ability

To reduce friction, maintain safe skin/tissue pressures and wick away moisture

To prevent complications

To promote optimal level of functioning

To promote commitment to plan, maximizing outcomes.

After the rotation and nursing intervention the significant other of the patient will:

a. Verbalize understanding of the situation /risk factors, individual therapeutic regimen and safety measures.

b. Demonstrate techniques/ behaviors that will enable safe repositioning

c. Maintain position of function and skin integrity of the patient as evidenced by absence of contractures, foot drop, decubitus, etc.

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:

“Hindi na makagalaw si nanay simula nung na-stroke siya ” as verbalize by the son of the patient

Obective:

(+) General body weakness

Tremors noted on left arm and hands

Inability to perform gross/fine motor skills

(+) Paralysis of left side of the body

functional level scale:

4 (does not participate in activity)

Impaired physical mobility related to Neuromuscular impairment

Hypertension

ˇ

Occlusion within vessels of the brain parenchyma

ˇ

Disruption of blood supply in the brain area

ˇ

Tissue and cell necrosis

ˇ

Destruction of Neuromuscular junctions

ˇ

Interruption in transportation of electrical impulses to the neuromuscular receptors

ˇ

MYALGIA/QUADRI OR HEMIPLEGIA

After the rotation and nursing intervention the patient will:

a. Maintain position and function and skin integrity as evidenced by absence of contractures, foot drop, decubitus and so forth.

b. S/O will demonstrate techniques/ behaviors that will enable safe repositioning

Determine diagnosis that contributes to immobility  (e.g. fractures, hemi/ para/ tetra/ quadriplegia)

Assess nutritional status and S/O others report of energy level.

Determine degree of immobility in relation to functional level scale

Assist or have significant other reposition client on a regular schedule (turn to side every 2 hours) as ordered by the physician

Provides safety measures (side rails up, using pillows to support body part)

Encourage patient’s S/O’s involvement in decision making as much as possible

Involve S/O in care, assisting them to learns ways of managing problems of immobility.

To identify causative/ contributing factors.

To assess functional ability

To prevent complication

To provide safety

Enhances commitment to plan optimizing outcomes

To impart health teaching.

After the rotation and nursing intervention the patient will:

c. Maintain position and function and skin integrity as evidenced by absence of contractures, foot drop, decubitus and so forth.

d. S/O will demonstrate techniques/ behaviors that will enable safe repositioning

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:

“Simula nung na i-stroke si  nanay, na bedridden na siya

Objective:

(+) NGT insertion

Patient is unable to:

[HYGIENE]

Access and prepare bath supplies

Wash body

Control washing mediums

[DRESSING AND GROOMING]

Obtain articles for clothing

Put on clothes

Maintain appearance at an acceptable level

[FEEDING]

Prepare/obtain food for ingestion

Handle utensils

Bring food to mouth

Chew and swallow up food

Pick up food

[TOILETING]

Go to the toilet

Self care deficit : hygiene, dressing and grooming, feeding and toileting related to Neuromuscular impairment

Hypertension

ˇ

Occlusion within vessels of the brain parenchyma

ˇ

Disruption of blood supply in the brain area

ˇ

Tissue and cell necrosis

ˇ

Destruction of Neuromuscular junctions

ˇ

Interruption in transportation of electrical impulses to the neuromuscular receptors

ˇ

MYALGIA/QUADRI OR HEMIPLEGIA

After the rotation and nursing interventions. The patient should:

a. meet all therapeutic self care demands in a complete absence of self care agency

b. ABSENCE OF S&S OF NUTRITIONAL DEFICIT. [Adequate nutritional intake]

c. GOOD SKIN TURGOR, NORMAL URINE OUTPUT, ABSENCE OF EDEMA, HYPER AND HYPOVOLEMIA [Fluid and Electrolyte balance]

d. ABSENCE OF DECUBITUS ULCERS AND FOUL ODORS IN BETWEEN LINENS/CLOTHING AND SKIN  [Clean, Intact skin and mucus membrane]

e. ABSENCE OF ABDOMINAL AND BLADDER DISTENTION, RECTAL FULLNESS AND PRESSURE, PAIN IN DEFECATION [ Meeting toileting demands ]

Provide enteric nutrition VIA NG Tube feeding. High fowlers for at least 15 minutes after feeding.

Careful I/O Monitoring and apply necessary dietary restrictions.

Change position at least ONCE every two hours or more often when needed.

Provide padding for the elbows, needs, ankles and other areas for possible skin abrasion.

An adult diaper should be WORN at all times. Change the diaper as soon as patient defecated.

Promote an Environment conducive to rest and recovery. Decrease stimuli and Metabolic demand of the body.

Passive ROM Exercises Early morning once a day, 10 times targeting both upper and lower extremities.

Lastly, Do health teaching when S/O is at the optimum level to receive information.

To meet patient’s need for an adequate nutritional intake.

To establish careful assessment on patients fluid and electrolyte balance.

To prevent decubitus ulcerations.

To protect the patient’s skin integrity maintaining his first line of defense against sickness and infection.

To prevent soiling of bed sheets, clothes and linens providing maximum comfort and prevention of skin irritation if feces remain in contact with the patient’s skin for a long time.

To conserve energy promoting rest and recovery.

This is to improve circulation, reducing the risk of atheromatous formation.

To educate the S/O what factors have contributed to the client’s illness and educating them to decrease, if not totally eliminate those contributory factors to prevent recurrence of the disease and promote change for a healthy lifestyle.

After the rotation and nursing interventions. The patient should:

f. meet all therapeutic self care demands in a complete absence of self care agency

g. ABSENCE OF S&S OF NUTRITIONAL DEFICIT. [Adequate nutritional intake]

h. GOOD SKIN TURGOR, NORMAL URINE OUTPUT, ABSENCE OF EDEMA, HYPER AND HYPOVOLEMIA [Fluid and Electrolyte balance]

i. ABSENCE OF DECUBITUS ULCERS AND FOUL ODORS IN BETWEEN LINENS/CLOTHING AND SKIN  [Clean, Intact skin and mucus membrane]

j. ABSENCE OF ABDOMINAL AND BLADDER DISTENTION, RECTAL FULLNESS AND PRESSURE, PAIN IN DEFECATION [ Meeting toileting demands ]