Republic of the Philippines

SULTAN KUDARAT STATE UNIVERSITY

ACCESS, EJC Montilla, Tacurong City

COLLEGE OF HEALTH SCIENCES

ICU NURSING CARE PLAN

PATIENT: A.B.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Date and Time Impaired After 12 hours Independent: Independent: "Goal partially
February 27, physical of nursing 1. Established met"
2024 at 7PM- mobility intervention rapport to the 1.To gains patient
related to the patient will patient. trust and
7AM physical be able to: cooperation.
After 12 hours of
deconditioning 2.Monitor vital signs nursing
Subjective: secondary to Short term frequently. 2. To obtain intervention the
N/A Postoperative goal: baseline data and patient was able
Appendectomy 1.Demonstrate 3. Assess client’s any signs of to:
techniques and condition. probable
Objective:
behaviors that abnormalities.
● Decrease enable safe 4. Determine 1. Verbalized
strength mobility diagnosis that 3. This is to understan
● Difficulty strategies and; contribute to determine any ding of
to 2. Understand immobility. conditions and to treatment
reposition situation and refer for proper regimen
individual 5. Note presence of medical
self and safety
therapeutic complications related interventions.
● Body regimen and to immobility. measures
weakness safety 4. To identify such as
observed. measures. 6. Assist with interventions the
 ● Facial Long term activities of hygiene, specific to client’s patient’s
grimace goal: feeding, and mobility willingnes
observed toileting. impairment and s to
1. Achieve needs.
● Guarding independence 7.Assist or have client
participate
behavior in performing reposition self on a 5. The effects of in a plan
noted daily activities regular schedule. immobility are of care or
with the least rarely confined to activities.
Vital signs as amount of Dependent: one body system 2. Shows
assistance. and can include
follows: progress
1.Assist with decline in
2. Maintain treatment of cognition, muscle on
BP:145/83 increase underlying wasting, increased
mmHg strength and conditions. contractures, strength
BT: 36.9⁰C function of pressure sores, and
RR:16 cpm affected or 2.Administer constipation, function
compensatory medication prior to aspiration,
PR:67 bpm as
body part. activity as needed for pneumonia, and
SPO2:96% pain relief. so forth. evidenced
by lifting of
3. Encourage 6. This allows both legs,
adequate intake of patient to upper
fluids and nutritious increase strength
extremitie
foods. and able to
participate in s and
ADL’s. repositioni
ng of self
7.Helps keep with least
blood flowing. amount of
This helps the skin
assistance
stay healthy and
prevents .
bedsores. Turning
a patient is a good
time to check the
skin for redness
and sores.

Dependent:

1.To maximize
potential for
mobility and
optimal function.

2.To permit
maximal effort
and involvement
in activity.

3.Promotes well-
being and
maximizes energy
productions.