CHINESE GENERAL HOSPITAL COLLEGE OF NURSING

NURSING CARE PLAN

Name: Boy M AGE: 9 y/o DIAGNOSIS: post – debridement and arthrothomy of the left leg

ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: SHORT TERM INDEPENDENT SHORT TERM
Client’s relative Knowledge deficit Client’s relatives may After 30min of health teaching, - Assess grandmother’s level of - Provide comparative baseline Goal was met
verbalized: related to patient’s grandmother will be anxiety related treatment and provide information about As evidenced by:
have knowledge
unfamiliarity with able to know the importance of plans and possible sepsis of needed a. Patient’s
deficit; defined as a
“Gumagaling naman ang proper and active participation in the client. education/intervention grandmother was
information
lack of cognitive alleviating her granddaughter’s regarding quality of life.
mga sugat ng apo ko sa able to state 3
resources
information or condition as evidenced by: - health teaching ways of the proper
mga dahon n itinatapal
psychomotor skills - discuss the different management of
ko.”
EXPECTED OUTCOME disease process inflammation of her
required for health
- State at least 3 ways of including the signs and grandson’s left leg
“Dati ganyan lang recovery, the proper management symptoms - Provide information to the - discussed that her
naman nawawala na maintenance, or of inflammation of her - discuss the possible client’s grandmother so as to grandson could not
yung pamamaga ng binti health promotion. grandson’s left leg. restriction in activity equip her with knowledge go to school for a
niya” because of her condition regarding the proper techniques moment until her
- Identify alternative ways - teach on proper skin and of care to an inflamed limb. grandson’s leg gets
of managing pain aside limb assessment well.
“Yan lang din ang
from medical aspect - demonstrate proper pain - Was able to identify
nakapagpagaling dun sa
that would alleviate the relief and anti- normal skin tone and
mga tao sa probinsya
discomfort inflammatory regimen to temperature during
namin.” LONG TERM the relatives and limb assessment.
- after 2 weeks of significant others. - demonstrated proper
nursing intervention - demonstrate proper leg elevation so as to
client’s grandmother will splinting techniques control pain
be able to perform inflammatory
proper leg care as process of the leg
 evidenced by: - To prevent overexertion secondary to disease
- Assist in adjusting activities - To reduce fatigue process.
EXPECTED OUTCOME - Gradually increase exercise
- aseptic way of leg care and activity - To enhance ability to LONG TERM
- Maintain the affected - Promote comfort measures participate in activities Goal was met as evidenced
leg free from any and provide for relief by:
unwanted pressure and a. client’s
ulceration. COLLABORATIVE grandmother was
- Coordinate with the family in - To have continuity of care able to perform
continuous monitoring of inner-to-outer way
activity of cleaning the
affected leg and
allowed adequate
tightness on the
elastic bandage
applied to the long
leg posterior mold.
b. Was able to
demonstrate pain
relief exercise
through elevation of
the affected leg
c. Was able to
maintain client’s leg
free from any
unwanted pressure