NURSING CARE PLAN

NURSING ACTUAL
ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME CRITERIA RATIONALE
INTERVENTIONS EVALUATION
SUBJECTIVE CUES Impaired Physical After performing SHORT TERM: Independent SHORT TERM:
Mobility related to comprehensive
“dli naman jud siya After 8 hours of nursing  Assisted with  To maximize the After 8 hours of
advanced stage IV breast nursing
kabarog kay tungod interventions, the treatment of potential for nursing
cancer. intervention the
sakit iya likod ug iya patient will be able to: underlying condition mobility and interventions, the
patient will be
cancer sad ni grabi” as causing dysfunction. function. patient was able to:
able to:  Maintain
verbalized by the
SCIENTIFIC BASIS: bodily function  Participate
patient’s significant  Maintain  Assessed for  Identifying the
 Participate in the
other For cancer patients, function impediments to specific cause
measures to activity but
immobility is a lack of and mobility. guides design of
increase only for a
movement that may be increase optimal treatment
mobility or limited
OBJECTIVE CUES caused by joint pain, body plan.
within limits of time.
muscle pain and stiffness, strength.
- Grimace face the disease.  Understand
malnutrition, cancer  Assessed patient’s  To be able to
noted .  Understand the
metastases, medication, significant other on assist the patient
- Requires the importance
anxiety or depression their knowledge on in position
assistance importance of of mobility
(CTCA, 2019). Functional safety and changes,
when mobility and and body
impairments are immobility. transfers and
ambulating or body function. function.
prevalent in patients with ambulation for its
doing ADL
advanced cancer and can LONG TERM: safety.
- Generalized
lead to disability,
weakness After 4 days of nursing LONG TERM:
increased caretaker
noted interventions, the  Assessed and
dependency, and  To maintain After 4 days of
- Range of patient will be able to: supported patient’s
psychological distress position of nursing
motion is only body parts that are
(Maltser, 2017). The  Evaluate function and interventions, the
limited in risk for pressure
neurological system, degree of reduce risk of patient was able to:
patient’s arm ulcers.
muscles and bones are pressure ulcers.
- Level of particularly vulnerable. functional  Instructed to keep  To promote  Evaluate
Independence= Problems with limb ability. side rails up and bed safety pf the the degree
4 ( is weakness and loss, gait  Promote in low position. patient. of patient’s
dependent and disturbance, imbalance optimal level functional
does not and other problems of function. ability.
participant) affecting normal walking  Identified energy  It limits fatigue,
are common in 25%–35% conserving g maximizing
of cancer patients technique for ADLs. participation.
(Christine Maheu, 2021)
 Instructed to turn the  To optimize
patient side to side circulation to all
every 2 hours or as tissue and relieve
needed. pressure.

 Provided positive  Patients may be

reinforcement during motivated to
activity. participate in the
activity.

Dependent
 Administer  To permit
medications as maximal effort
needed before the and involvement
activity of activity.
 Collaborative
 Referred and  To further
evaluated in evaluate patient’s
rehabilitation, if optimum bodily
patient’s is in need of function.
assistive devices.

 Performed passive  To promote

assistive range of increased venous
motion exercise. return, prevent
stiffness and
maintain muscle
strength and
endurance.

References
Christine Maheu, R. C. (2021). Mobility Impairment. Retrieved from Cancer and Work: https://www.cancerandwork.ca/healthcare-providers/cancers-impact-on-work/effects-mobility/
CTCA. (2019). Immobility. Retrieved from Cancer Treatment Centers of America: https://www.cancercenter.com/integrative-care/immobility
Maltser, S. C. (2017). A Focused Review of Safety Considerations in Cancer Rehabilitation. The journal of injury, function and rehabilitation, 9(9S2).