West Visayas State University

College of Nursing
NURSING CARE PLAN
Name of Patient: A.M. Attending Physician: Dr. S
Age: 19 y.o. Ward/Bed Number: OSW/ 9 Impression/Diagnosis: Pott’s disease
Objectives of
Clustered Cues Nursing Rationale Care/Outcome Criteria Nursing Interventions Rationale Evaluation
Diagnosis (Subject+Verb+
(Scientific Basis) (Scientific Basis)
Condition+Criteria+
Target Time)
July 22, 2011; Impaired Impaired physical The client will be able to  Assess the client.  To determine the factors -not evaluated
5:00 PM physical mobility is the maintain skin integrity, that may contribute to
mobility limitation in function of affected and client's immobility.
“Indi ako related to independent, unaffected body parts,
kahulag sang inability to purposeful physical and absence of  Observe client’s  To note any
maayo kay indi move lower movement of the body contractures by July 29, movement when he is incongruencies with
ko mahulag akon extremities or of one or more 2011 at 7:00 AM. unaware. reports of abilities.
hawak extremities.
padalum”, as  Plan activities to provide  Prevents fatigue.
verbalized by uninterrupted rest
AM. periods.
 Enhances self-concept
 Difficulty  Encourage participation and sense of
turning in self-care. independence

 absent range  Support affected body  To maintain position of

of motion of parts using pillows, foot function and reduce risk
lower support. of pressure ulcers.
extremities
 Perform passive ROM  Enhances circulation,
exercise on lower restores or maintains
extremity, using slow muscle tone and joint
and smooth mobility, and prevents
movements. disuse contractures and
muscle atrophy.
  Impaired  Encourage adequate
sensory and intake of fluids and  Promotes well-being and
motor nutritious foods. maximizes energy
function in Reference: production.
lower Doenges, M.,Moorhouse,  Inspect skin daily. Assess
M., Murr, A., Nurse’s Pocket
extremities th
Guide 11 Edition (2008),
for pressure areas, and  Loss of sensation and
provide meticulous skin paralysis potentiate
 Kyphotic care. pressure sore formation.
posture
 Observe proper body  To prevent contractures
alignment when and promote good
positioning the client. circulation.

 Change clients position,  To prevent formation of

as ordered. pressure ulcers and
pulmonary complication.

Student’s Name:
Clinical Instructor:
 West Visayas State University
College of Nursing
NURSING CARE PLAN
Name of Patient: A.M. Attending Physician: Dr. S
Age: 19 y.o. Ward/Bed Number: OSW/ 9 Impression/Diagnosis: Pott’s disease
Objectives of
Clustered Cues Nursing Rationale Care/Outcome Criteria Nursing Interventions Rationale Evaluation
Diagnosis (Subject+Verb+
(Scientific Basis) (Scientific Basis)
Condition+Criteria+
Target Time)
7/22/11: Disturbed Confusion and/or The client will be able
5:30pm body image dissatisfaction in to verbalize  Discuss the  To increase Not evaluated
related to mental picture of one's understanding of disease awareness and
“Nasubuan gid the physical self. changes in the body according to understanding
ko kay damu and identify feelings clients level of
deformities and methods for understanding.
gasunlog sa akun brought about Pott's disease or
nga bugtot “,as by the disease coping with negative
tuberculous spondylitis perception of self by  Support and  Caregivers
verbalized by is a rare grave form of
condition. 7/23/11. encourage client; sometimes allow
A.M tuberculosis caused by provide care with judgmental
the invasion of a positive and feelings to affect
“Sang-una kaya Mycobacterium friendly attitude. the care of client
ko pa mag ubra tuberculosis into the and need to
sang damu nga spinal vertebrae. The make every
bagay subong intervertebral disks effort to make
gasalig nalang ko may be destroyed client feel valued
sa iban “as as a person.
resulting in the
verbalized by  Provide
collapse and wedging
A.M assistance with  To assist client to
of affected vertebrae self care needs deal with issues
and the shortening and while promoting of self concept
kyphotic posture angulation of the spine related to body
individual
causing deformities. abilities or image.
independence.
Deformity refers to the
distortion,
disfigurement,flaw,or
 malformation that  Encourage client  To address
affects the body in and significant realities and
general or any part of others to provide
it.Any perceived verbalize feelings emotional
to each other. support.
change in structure or
function of a body part
can lead to disturbed  Discuss concerns  To incorporate
body image. about fear of changes to body
rejection when image.
client is facing
Source: Doenges, poor outcome of
M.,Moorhouse, M., Murr, illness.
A., Nurse’s Pocket Guide
th
11 Edition (2008), F.A.
 Encourage client
Davis Company,
Pennnsylvania,p 115
to touch affected Sources: Doenges,
body parts. M.,Moorhouse, M., Murr,
Mosby’s Pocket A., Nurse’s Pocket Guide
11th Edition (2008), F.A.
Dictionary of Medicine,
Davis Company,
Nursing and Health
Pennnsylvania,p,117-120
Professions, 5th Edition
(2006), Elsevier
Singapore,
p,187,385,1409

Student’s Name:
Clinical Instructor: