NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Cues: Impaired physical mobility Short Term: Independent: Independent: Short Term:
 Flaccid right related to neuronal cell After 2 hours of nursing 1.) Assess client’s developmental level, 1.) Determines presence of After 2 hours of nursing
leg observed damage AEB flaccid right intervention, SO will be able motor skills, and ease and capability of characteristics of client’s unique intervention, SO shall have
 Noted leg to verbalize understanding movement. impairment and to guide choice of verbalized understanding of
absence of of the disease process, risk interventions. the disease process, risk
deep tendon factors, and treatment factors, and treatment
reflex and modalities. 2.) Assess strength to perform ROM to 2.) Verifies extent of physical modalities.
Babinski all joints. problems and guides therapy.
reflex on Long Term: Long Term:
right leg After 8 hours to 5 days of 3.) Assess the client’s skin color and for 3.) Immobility may lead to the After 8 hours to 5 days of
 No nursing intervention, client lesions. development of pressure sores. nursing intervention, the
abnormalities will be able to achieve and client shall have achieved
presented on maintain strength and 4.) Assess the safety of the 4.) Children’s toys and lowered and maintained strength
other limbs function of limbs AEB no environment. side rails may cause injury and risk and function of right leg
May Manifest: signs of muscle atrophy. for falls. AEB no signs of muscle
 Decrease in atrophy.
range of 5.) Note elimination status. 5.) Immobility decreases the
motion motility of the gastrointestinal
 Decrease in tract, promoting constipation.
muscle size,
tone, and 6.) Assist patient for muscle exercises as 6.) Aids in strengthening muscles
strength able such as ROM exercises. and maintaining muscle tone.
 Abnormal
breathing 7.) Support affected body parts using 7.) Maintains a position of
pattern pillows, rolls, gel pads, or foam. function and reduces risk for
 Nasal flaring pressure ulcers.
8.) Provide rest periods and consider
 Presence of energy-saving techniques. 8.) Rest periods are essential to
redness or conserve energy.
lesions on 9.) Clean, dry, and moisturize skin as
the affected necessary. 9.) Prevents breakdown of skin
area and formation of pressure ulcers.
10.) Raise side rails and lower the bed.
10.) Promotes a safe and secure
environment and reduces the risk
for falls.
11.) Turn and position the patient every
2 hours or as needed. 11.) Position changes optimize
circulation to tissues and relieve
pressure.
Dependent:
12.) Assist in administering medications, Dependent:
as indicated. 12.) Medications such as
analgesics may reduce pain.
13.) Report to physician any variation
from normal. 13.) Any variation may pose a
threat to the patient.
Interdependent:
14.) Provide for diet instructions such as Interdependent:
increasing food high in fiber and fluid 14.) Increasing the intake of fiber-
intake. rich foods and fluids may prevent
the occurrence of constipation.
15.) Inform of necessity of regular
medical and laboratory follow-up. 15.) Ensure updated health status.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Cues: Imbalanced nutrition: less Within my duty, the client 1.) Ascertain healthy body weight for 1.) Experts like a dietician can After my duty, the client
 Anorexia than body requirement will be able to improve and age and height. Refer to a dietitian for determine nitrogen balance as a will be able to improve and
 Nausea related to anorexia, nausea, maintain a nutritious diet. complete nutrition assessment and measure of the nutritional status maintain a nutritious diet.
 Vomiting and vomiting. methods for nutritional support. of the patient. A negative nitrogen
balance may mean protein
malnutrition. The dietician can
also determine the patient’s daily
requirements of specific nutrients
to promote sufficient nutritional
intake.
2.) Set appropriate short-term and long-
term goals. 2.) Patients may lose concern in
addressing this dilemma without
realistic short-term goals.
3.) Provide a pleasant environment.
3.) A pleasing atmosphere helps in
decreasing stress and is more
favorable to eating.
4.) Promote proper positioning.
4.) Elevating the head of bed 30
degrees aids in swallowing and
reduces risk for aspiration with
eating.
5.) Provide good oral hygiene and
dentition. 5.) Oral hygiene has a positive
effect on appetite and on the
taste of food. Dentures need to be
clean, fit comfortably, and be in
the patient’s mouth to encourage
6.) If patient lacks strength, schedule eating.
rest periods before meals and open
packages and cut up food for patient.
7.) Provide companionship during
mealtime.
8.) Consider the use of seasoning for
patients with changes in their sense of
taste; if not contraindicated.
9.) Consider six small nutrient-dense
meals instead of three larger meals
daily to lessen the feeling of fullness.
10.) For patients with physical
impairments, refer to an occupational
therapist for adaptive devices.
11.) For patients with impaired
swallowing, coordinate with a speech
therapist for evaluation and instruction.
12.) Determine time of day when the
patient’s appetite is at peak. Offer
highest calorie meal at that time.
13.) Encourage family members to bring
6.) Nursing assistance with
activities of daily living (ADLs) will
conserve the patient’s energy for
activities the patient values.
Patients who take longer than one
hour to complete a meal may
require assistance.
7.) Attention to the social
perspectives of eating is important
in both hospital and home
settings.
8.) Seasoning may improve the
flavor of the foods and attract
eating.
9.) Eating small, frequent meals
lessens the feeling of fullness and
decreases the stimulus to vomit.
10.) Special devices may be
provided by an expert that can
help patients feed themselves.
11.) Adjustments of the thickness
and consistency of foods to
improve nutritional intake may be
provided by a speech therapist.
food from home to the hospital.
14.) Offer high protein supplements
based on individual needs and
capabilities.
15.) Offer liquid energy supplements.
16.) Discourage caffeinated or
carbonated beverages.
17.) Keep a high index of suspicion of
malnutrition as a causative factor in
infections.
18.) Encourage exercise.
19.) Consider the possible need for
enteral or parenteral nutritional
support with the patient, family, and
caregiver, as appropriate.
12.) Patients with liver disease
often have their largest appetite
at breakfast time.
13.) Patients with specific ethnic
or religious preferences or
restrictions may not consider
foods from the hospital.
14.) Such supplements can be
used to increase calories and
protein without conflict with
voluntary food intake.
15.) Energy supplementation has
been shown to produce weight
gain and reduce falls in frail
elderly living in the community.
16.) These beverages will decrease
hunger and lead to early satiety.
17.) Impaired immunity is a critical
adjunct factor in malnutrition-
associated infections in all age
groups.
18.) Metabolism and utilization of
nutrients are improved by activity.

20.) Validate the patient’s feelings
regarding the impact of current
lifestyle, finances, and transportation
on ability to obtain nutritious food.
21.) Once discharged, help the patient
and family identify area to change that
will make the greatest contribution to
improved nutrition.
22.) Adapt modification to their current
practices.
19.) Nutritional support may be
recommended for patients who
are unable to maintain nutritional
intake by the oral route. If
gastrointestinal tract is
functioning well, enteral tube
feedings are indicated. For those
who cannot tolerate enteral
feedings, parenteral nutrition is
recommended.
20.) Validation lets the patient
know that the nurse has heard
and understands what was said,
and it promotes the nurse-patient
relationship.
21.) Change is difficult. Multiple
changes may be overwhelming.
22.) Accepting the patient’s or
family’s preferences shows
respect for their culture.