Identified Problem Identified Needs Nursing Diagnosis Nursing Actions Rationale

HOLY‌‌‌NAME‌‌‌UNIVERSITY‌‌‌
‌
COLLEGE‌‌‌OF‌‌‌HEALTH‌‌‌SCIENCES‌‌‌ ‌
NURSING‌‌‌DEPARTMENT‌‌‌ ‌
City‌‌‌of‌‌‌Tagbilaran‌‌‌ ‌
‌ ‌
‌ ‌
NURSING‌‌‌CARE‌‌‌PLAN‌‌ ‌
Name of Patient: _____________________________________________________

Mrs. D Age: _________ ___________________ Status: ___________________________________
78 years old Widow
Address: ______________________________________________________ Date: ____________________________Ward: ______________________ Bed No. _______________

fractured neck of the femur, malnutrition and a need for a new living arrangement
Impression: _______________________________________________________________________________________________________________________
Identified Identified Needs Nursing Diagnosis Nursing Actions Rationale

Problem
A fractured neck of -The client needs to Impaired physical mobility Independent Actions:
the femur maintain or increase body related to fracture as
 Assess the degree of immobility  The patient may be
strength and function of evidenced by reluctance to
produced by injury or treatment and restricted by self-view or
affected and/or attempt movement; limited
note the patient’s perception of self-perception out of
compensatory body part. ROM immobility. proportion with actual
physical limitations,
requiring information or
interventions to promote
progress toward wellness.
 Encourage the use of isometric  Isometrics contract muscles

exercises starting with the unaffected without bending joints or
limb. moving limbs and help
maintain muscle strength
and mass. These exercises
are contraindicated while
HOLY‌‌‌NAME‌‌‌UNIVERSITY‌‌‌ ‌
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acute bleeding and edema

are present.
 Encourage increased fluid intake to  Keeps the body well

2000–3000 mL per day (within cardiac hydrated, decreasing the
tolerance), including acid or ash juices. risk of urinary infection,
stone formation, and
constipation
 Instruct and encourage the use of  Facilitates movement during

trapeze and “postposition” for lower hygiene or skincare and
limb fractures. linen changes; reduces the
discomfort of remaining flat
in bed. “Post position”
involves placing the
uninjured foot flat on the
bed with the knee bent
while grasping the trapeze
and lifting the body off the
bed.
Dependent Action:
 Administer medications prior to  To permit maximal effort
activity as needed for pain relief and involvement in activity
prescribed by the physician.
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Collaborative Actions:
 Collaborate with physical medicine  To develop individual
specialist and occupational or physical exercise and mobility
therapists in providing range-of- program, to identify
motion exercise (active or passive), appropriate mobility
isotonic muscle contractions (e.g., devices, and top limit or
flexion of ankles, push and pull reduce effects and
exercises), assistive devices, and complications of immobility
activities (e.g., early ambulation,
transfers, stairs)
Malnutrition -The client needs to Imbalanced Nutrition: Less Independent Actions:

verbalize understandings of than body requirements  Set appropriate short-term and long-  Patients may lose concern in
causative factors when related to psychological term goals. addressing this dilemma
known and necessary factors as evidenced by without realistic short-term
interventions. The client anxiety, insecurity, loneliness goals.
needs to demonstrate and depression.
progressive weight gain  Provide a pleasant environment.  A pleasing atmosphere
toward goal helps in decreasing stress
and is more favorable to
eating.
 If patient lacks strength, schedule rest
periods before meals and open  Nursing assistance with
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‌ ‌
packages and cut up food for patient. 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.
 Provide good oral hygiene and
dentition.  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 eating.
 Collaborate with interdisciplinary
team  To wet nutritional goals
when client has specific
dietary needs, malnutrition
is profound, or long-term
feeling problems exist.
 Consult with dietician or nutritional
support team, as necessary  For long term needs
A need for a new living -The client needs to discuss Spiritual Distress related to Independent Actions:
arrangement beliefs and values about separation or death of support  Provide calm, peaceful setting when  Promotes relaxation and
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spiritual issues. system related to inability to possible. enhances opportunity for

-The Client needs to attend masses in the church reflection on situation,
identify meaning and discussions with others, and
purpose in own life that meditation.
reinforces hope, peace,
and contentment  Have client identify and prioritize  Helps client focus on what
-The client needs to current or immediate needs. needs to be done and
verbalize increased sense identify manageable steps
of connectedness and hope to take.
for future
 Involve client in refining healthcare  Enhances commitment to
goals and therapeutic regimen, as plan, optimizing outcomes.
appropriate.
 Assist client to learn use of  To heal past hurts.

meditation, prayer, and forgiveness
 Encourage life-review by client. Help  Promotes sense of hope and

client find a reason for living. willingness to continue
efforts to improve situation.
 Assist client to identify that could be  Can be helpful in finding
helpful (e.g., contact spiritual advisor answers to spiritual
who has qualifications or experience questions, assisting in
in dealing specific problems, such as journey of self-discovery,
death and dying, relationship and helping client learn to
problems, substance abuse, suicide.) accept and forgive self.
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 Refer to appropriate resources (e.g.,  Useful in dealing with

pastoral or parish nurse, religious immediate situation and
counselor, crisis counselor, hospice; identifying long-term
psychotherapy; Alcoholics or Narcotics resources for support to
Anonymous). help foster sense of
connectedness.

Identified Problem Identified Needs Nursing Diagnosis Nursing Actions Rationale

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HOLY‌‌‌NAME‌‌‌UNIVERSITY‌‌‌

Name of Patient: _____________________________________________________

Address: ______________________________________ Date: Ward: Bed No. _

Identified Identified Needs Nursing Diagnosis Nursing Actions Rationale

 Encourage the use of isometric  Isometrics contract muscles

acute bleeding and edema

 Encourage increased fluid intake to  Keeps the body well

 Instruct and encourage the use of  Facilitates movement during

Malnutrition -The client needs to Imbalanced Nutrition: Less Independent Actions:

packages and cut up food for patient. activities of daily living

spiritual issues. system related to inability to possible. enhances opportunity for

 Assist client to learn use of  To heal past hurts.

 Encourage life-review by client. Help  Promotes sense of hope and

 Refer to appropriate resources (e.g.,  Useful in dealing with

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