Ella Mae O.

Estrella BSN - 4
Nursing Care Plan
Nursing
Cues Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Impaired Physical Short Term Goal Independent Short Term Goal
 “Asawa ko Mobility related to After 8 hours of effective  Assess the patient's ability to  Restricted movement affects Goal partially met:
nag lilinis ng decreased muscle nursing intervention: perform ADLs effectively and the ability to perform most After 8 hours of
sugat ko, endurance,  Patient will perform safely on a daily basis using an ADLs. A variety of assessment effective nursing
hindi ko kasi strength and simple muscle appropriate assessment tool, tools are available, such tools intervention:
kaya. Mahina control as exercises such as the Functional provide objective data for  Patient performed
kasi kalahati manifested by demonstrated by the Independence Measures (FIM). baselines. simple muscle
ng katawan one sided nurse  Execute passive or active  Exercise enhances increased exercises
ko” as paralysis, slowed  Patient will initiate on assistive ROM exercises to all venous return, prevent demonstrated by
verbalized by movement and doing simple ADLs extremities stiffness and maintains muscle the nurse
the patient inability to (e.g. getting and strength and stamina. It also  Patient verbalized
perform ADLs drinking a cup of avoids contracture understanding
Objective: independently. water), independent deformation, which can build about the use of
 Limited range as possible up quickly and could hinder assistive/
of motion  Patient will verbalized prosthesis usage mobility devices
 Difficulty understanding about  These devices can (e.g. crane,
 Show the use of mobility devices,
performing the use of compensate for impaired crutches, walker)
such as the following: trapeze,
ADLs assistive/mobility function and enhance level of  Patient verbalized
crutches or walkers
independently devices (e.g. crane, activity. The goals of using understanding
 Slowed crutches, walker) such aids are to promote and displayed
movements  Patient will verbalized safety, enhance mobility, enthusiasm in
 Inability to understanding and avoid falls and conserve learning about
perform display enthusiasm in energy. the importance of
wound learning about the  Adds to gaining enhanced independent self-
 Assist patient for muscle
dressing importance of sense of balance and care
exercises as able or when
independently independent self-care strengthens compensatory
allowed out of bed; execute
body parts Long Term Goal
abdominal tightening exercises
Long Term Goal Goal partially met:
and knee bends; hop on foot;
At least 24 hours before 24 hours before
stand on toes
hospital discharge:  These measures promote a hospital discharge:
 Provide a safe environment: bed
 Patient will perform safe, secure environment and  Patient performed
rails up, bed in down position,
every muscle may reduce risk for falls. every muscle
necessary items close by.
exercises, patient  Acceptance of temporary or exercises, patient
 Assess the emotional response to
used every day, more permanent limitations used every day,
the disability or limitation.
demonstrated by the can vary widely among demonstrated by
nurse individuals. Each person has the nurse
 Patient will perform his or her own definition of  Patient performed
physical activities acceptable quality life physical activities
such as personal care;  Reduced activity and such as personal
hygiene and  Assess elimination status (e.g., immobility decrease care; hygiene and
grooming, exercises… usual pattern, present patterns, gastrointestinal motility grooming,
signs of constipation). exercises…
 independently  Encourage and facilitate early
 Patient will use ambulation when possible. Assist
assistive/mobility with each initial change: dangling
devices (e.g. crane, legs, sitting in chair, ambulation.
crutches, walker) to
move independently.
 Patient together with
SO will demonstrate  Facilitate transfer training by
technique uses, to teaching or using appropriate
ensure safety by techniques or devices when
minimizing potential transferring patients to bed, chair,
risk for injury or stretcher.
 Allow the patient to perform tasks
at his or her own rate. Do not
rush the patient. Encourage
independent activity as able and
safe.
 Provide positive reinforcement
during activity.
 Provide the patient of rest periods
in between activities. Consider
energy – saving techniques.
 Encourage resistance training
exercises using light weights
when suitable
 Explain progressive activity to the
patient. Help the patient or
caregivers establish reasonable
and obtainable goals.
 These activities keep the independently
patient as functionally active  Patient used
as possible. Early mobility assistive/mobility
promotes confidence about devices like crane
regaining independence and and crutches to
reduces the chance that move
debilitation will occur. independently.
 Learning the correct way to
transfer is important for
maintaining optimal mobility
and patient safety
 Hospital workers and family
caregivers are often in a hurry
and do more for patients than
needed, thereby slowing the
patient's recovery and
reducing his or her self-
esteem. Rest periods are
necessary to conserve energy.
The patient must learn to
respect the limitations of his or
her restrictions.
 Patients may be reluctant to
move or initiate new activity
because of a fear of falling. A
positive approach allows the
learner to feel good about
learning accomplishments.
 Rest periods are essential to
conserve energy. The patient
must learn and accept his or
her limitation
 Strength training and other
forms of exercises are
believed to be effective in
maintain independent living
status and reduced the risk of
falling in older adults
 Information promotes
awareness of the treatment
plan. Setting small, attainable
goals helps increase self-
confidence and educes
frustration
 This enhances sense of

 Set goals with patient or
significant other for cooperation in
activities or exercise and position
change
 Teach patient or family in
maintaining home atmosphere
hazard free and safe
 Give explanation about
progressive activity to patient
Dependent
 Give medications as
prescribed/appropriate
anticipation of progress or
improvement and gives some
sense of control or
independence
 A safe environment will help
prevent injury related to falls.
Home modification can help
the patient maintain a desired
level of functional
independence and reduce
fatigue with activity
 Providing small, attainable
goals helps increases self-
confidence and reduces
frustration
 Antipasmodic medication may
reduce muscle spasms or
spasticity that interferes with
mobility, analgesics may
reduce pain that impedes
movement