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Nursing Care Plan Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Nursing Care Plan Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
kapag gumagalaw as verbalized by the son of the patient. bjective: !mpaired ability to turn side to side !mpaired ability to move from supine to sitting vise versa. "#$ presence of pelvic fracture "#$ %eneral weakness &remors noted on left arm and hands "#$ %eneral body weakness b. NURSING DIAGNOSIS ' !mpaired physical mobility related to pain secondary to musculoskeletal impairment as evidenced by body weakness PLANNING (fter ) hours of nursing intervention the patient will: a. *erbalize understanding of the situation +risk factors, individual therapeutic regimen and safety measures. -emonstrate techni.ues+ behaviors that will enable safe repositioning /aintain position of function and skin integrity of the patient as evidenced by absence of contractures, foot drop, decubitus, etc. INTERVENTION determine diagnoses that contribute to immobility "e.g. fractures, hemi+para+tetra+.uadrip egia$ 0ote individual risk factors and current situation, such pain, age, general weakness, debilitation -etermine perceptual+ cognitive impairment to follow directions -etermine functional level classification 0ote presence of complications related to immobility bserve skin for reddened areas+shearing. 1rovide appropriate pressure to relief 1rovide regular skin care if appropriate (ssist with activities of hygiene, toileting, feeding, as indicated. !nvolve client S+ in determining activity schedule RATIONALE &o identify causative+ contributing factors. EVALUATION (fter ) hours of nursing intervention the patient was a. *erbalized understanding of the situation +risk factors, individual therapeutic regimen and safety measures. -emonstrated techni.ues+ behaviors that will enable safe repositioning /aintained position of function and skin integrity of the patient as evidenced by absence of contractures, foot drop, decubitus, etc.
b.
c.
&o reduce friction, maintain safe skin+tissue pressures and wick away moisture &o prevent complications &o promote optimal level of functioning
ASSESSMENT Subjective: Hindi na makagalaw si nanay simula nung na3 stroke siya as verbalize by the son of the patient bective: "#$ %eneral
INFERENCE Hypertension cclusion within vessels of the brain parenchyma 4 -isruption of blood supply in the brain area 4 &issue and cell necrosis
PLANNING (fter the rotation and nursing intervention the patient will: a. /aintain position and function and skin integrity as evidenced by absence of contractures,
INTERVENTION -etermine diagnosis that contributes to immobility "e.g. fractures, hemi+ para+ tetra+ .uadriplegia$ (ssess nutritional status and S+ others report of energy level. -etermine degree
EVALUATION (fter the rotation and nursing intervention the patient will: c. /aintain position and function and skin integrity as evidenced by absence of contractures, foot drop,
body weakness &remors noted on left arm and hands !nability to perform gross+fine motor skills "#$ 1aralysis of left side of the body functional level scale: 5 "does not participate in activity$
4 -estruction of 0euromuscular junctions 4 !nterruption in transportation of electrical impulses to the neuromuscular receptors 4 /6(7%!(+89(-: ! : H;/!17;%!(
b.
foot drop, decubitus and so forth. S+ will demonstrate techni.ues+ behaviors that will enable safe repositioning
of immobility in relation to functional level scale (ssist or have significant other reposition client on a regular schedule "turn to side every < hours$ as ordered by the physician 1rovides safety measures "side rails up, using pillows to support body part$ ;ncourage patient=s S+ =s involvement in decision making as much as possible !nvolve S+ in care, assisting them to learns ways of managing problems of immobility.
d.
decubitus and so forth. S+ will demonstrate techni.ues+ behaviors that will enable safe repositioning
ASSESSMENT Subjective: Simula nung na i3 stroke si nanay, na bedridden na siya bjective: "#$ 0%& insertion 1atient is unable to: >H6%!;0;? (ccess and prepare bath supplies @ash body Aontrol washing mediums >-:;SS!0% (0%: /!0%? btain articles for clothing 1ut on clothes /aintain appearance at an acceptable level >B;;-!0%? 1repare+obtain food for ingestion Handle utensils Cring food to mouth Ahew and swallow up food
NURSING DIAGNOSIS Self care deficit : hygiene, dressing and grooming, feeding and toileting related to 0euromuscular impairment
INFERENCE Hypertension cclusion within vessels of the brain parenchyma 4 -isruption of blood supply in the brain area 4 &issue and cell necrosis 4 -estruction of 0euromuscular junctions 4 !nterruption in transportation of electrical impulses to the neuromuscular receptors 4 /6(7%!(+89(:! : H;/!17;%!(
PLANNING (fter the rotation and nursing interventions. &he patient should: a. meet all therapeutic self care demands in a complete absence of self care agency b. (CS;0A; B SDS B 09&:!&! 0(7 -;B!A!&. >Adequate nutritional intake] c. % - SE!0 &9:% :, 0 :/(7 9:!0; 9&19&, (CS;0A; B ;-;/(, H61;: (0H61 * 7;/!( >Fluid and Electrolyte balance] d. (CS;0A; B -;A9C!&9S 97A;:S (0B 97 - :S !0 C;&@;;0 7!0;0S+A7 &H!0 % (0- SE!0 >Clean, Intact skin and mucus membrane] e. (CS;0A; B (C- /!0(7
INTERVENTION 1rovide enteric nutrition *!( 0% &ube feeding. High fowlers for at least FG minutes after feeding. Aareful !+ /onitoring and apply necessary dietary restrictions Ahange position at least 0A; every two hours or more often when needed. 1rovide padding for the elbows, needs, ankles and other areas for possible skin abrasion. (n adult diaper should be @ :0 at all times. Ahange the diaper as soon as patient defecated.
RATIONALE &o meet patient=s need for an ade.uate nutritional intake. &o establish careful assessment on patients fluid and electrolyte balance. &o prevent decubitus ulcerations.
EVALUATION (fter the rotation and nursing interventions. &he patient should: f. meet all therapeutic self care demands in a complete absence of self care agency g. (CS;0A; B SDS B 09&:!&! 0(7 -;B!A!&. >Adequate nutritional intake] h. % - SE!0 &9:% :, 0 :/(7 9:!0; 9&19&, (CS;0A; B ;-;/(, H61;: (0H61 * 7;/! ( >Fluid and Electrolyte balance] i. (CS;0A; B -;A9C!&9S 97A;:S (0B 97 - :S !0 C;&@;;0
&o protect the patient=s skin integrity maintaining his first line of defense against sickness and infection. &o prevent soiling of bed sheets, clothes and linens providing ma2imum
(0- C7(--;: -!S&;0&! 0, :;A&(7 B9770;SS (01:;SS9:;, 1(!0 !0 -;B;A(&! 0 > Meeting toileting demands ?
1romote an ;nvironment conducive to rest and recovery. -ecrease stimuli and /etabolic demand of the body. 1assive : / ;2ercises ;arly morning once a day, FH times targeting both upper and lower e2tremities. ' 7astly, -o health teaching when S+ is at the optimum level to receive information.
comfort and prevention of skin irritation if feces remain in contact with the patient=s skin for a long time. &o conserve energy promoting rest and recovery.
j.
7!0;0S+A7 & H!0% (0SE!0 >Clean, Intact skin and mucus membrane] (CS;0A; B (C- /!0(7 (0C7(--;: -!S&;0&! 0, :;A&(7 B9770;SS (01:;SS9:;, 1(!0 !0 -;B;A(&! 0 > Meeting toileting demands ?
FH. &o educate the S+ 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.