Republic of the Philippines

SULTAN KUDARAT STATE UNIVERSITY

ACCESS, EJC Montilla, Tacurong City

COLLEGE OF HEALTH SCIENCES

NURSING CARE PLAN

OR NURSING CARE PLAN

PATIENT: DELA CRUZ, JOMARTIN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Date and time: Impaired After 12 hours of 1. Establish Rapport 1. Establishing rapport “GOAL PARTIALLY
physical nursing intervention, with the client. gains patient’s trust MET”
February 06,2024 at mobility related the patient will be 2. Continually assess and attention.
7:00 AM – 7:00 PM. able to: motor function by 2. Evaluate status of After 12 hours of
to spinal injury
requesting patient to individual situation for nursing intervention,
as evidenced level of injury.
perform certain the goal was partially
by limited range Short term goals: actions 3. To determine any
Subjective: of motion and met, as the patient:
3. Monitor Vital signs abnormalities and to
difficulty with 1. Demonstrate frequently refer to the physician
N/A” 1. Was not able to
changing techniques or for immediate
demonstrate
position behaviors that 4. Facilitate safety by interventions.
4. To promote safety techniques or
enable pulling up side rails
environment behaviors that
resumption of 5. Encourage patient to
5. To allow body and enable
Objective: activity have adequate rest mind to recharge and resumption of
2. Verbalize period as well as function properly.
- Paralysis on activity
understanding comfort and safety 6. Promotes wellbeing
lower extremities 2. Patient was able
of his measures to the and to recover quickly
- Muscle atrophy to verbalize
condition patient. 7. To relief moderate to
understanding of
 - Grimace face Long term goals: 6. Encourage adequate moderately severe his condition
notes nutrition and fluid pain
- Limited Range 1. Patient intake 3. The patient has
of Motion performs 7. Administer not exhibited any
- Gunshot wounds physical medication as observable signs
on the back activity ordered of mobility but
independently has a stable vital
Vital Signs: or within limits sign as
of injury evidenced by:
BP: 90/60
RR: 23 Cycle per BP:90/60,
minute HR:69bpm,
PR: 69 bpm RR:23
SpO2: 95% TEMP: 36.8°C
Temp: 36.5°C
Spo2: 96%