Krystlle Lyre G.

Cordero
Clinical Instructor: Mrs. Ramon A. Galicia, RN
4BCN
San Beda College

NURSING CARE PLAN

Patient’s Name: C.F
Age: 15 years old
Dx: Osteogenesis Imperfecta Fracture, closed complete middle 3rd femur right

SCIENTIFIC NURSING
ASSESSMENT DIAGNOSIS PLANNING RATIONALE EVALUATON
RATIONALE INTERVENTION
Subjective: Self-Care Due to Resources will Independent: The resources
 “Nahihirapa Deficit in limitations in the be identify  Establish rapport  To establish rapport on were identified
n ako kumilos bathing/ individual’s which are on the client. the client. which are useful in
lalo na sa hygiene,dressi ability to useful in  Monitor vital  To obtain the baseline optimizing the
pagligo, ng/grooming, ambulate, he is optimizing the signs. data. autonomy and
pagkain” as feeding and prevented from autonomy and  If in a typical  Observation of bathing independence of
verbalized by toileting RT performing ADLs independence bathing setting for performed in an the patient in his
the patient. Musculoskelet that allow her to of the patient the client, assess atypical bathing hygiene, dressing
al Impairment manage her the client’s ability to setting may result in or grooming,
Objective: Secondary to hygiene such as bathe self via direct false data for which feeding and in
 Inability to Fracture bathroom observation using use of a physical toileting.
feed self Femur privileges, physical performance test
independently bathing, clothing performance tests compensates to
 Inability oneself. for ADLs. provide more accurate
to dress self  Provide health ability data.
independently teaching on the  To provide adequate
 Inability client regarding the knowledge on the
to bathe and proper way on client.
groom self effective oral
independently hygiene.
 To provide correct
 Inability  Explain the pattern of performing
to perform procedure of proper the procedure.
toileting bathing and hair
tasks brushing on the  Individualized bathing
independently patient. produces a more
 Inability  Individualize positive bathing
to ambulate bathing by experience and
independently identifying function preserves client
of bath (e.g., odor, dignity. Client
urine removal), aggression is increased
frequency required with shower
to achieve function, (especially) and tub
and best bathing bathing. Towel bathing
form (e.g., towel increases privacy and
bathing, tub, eliminates need to
shower) to meet move the client to
client preferences, central bathing area;
preserve client therefore it is a more
dignity, make soothing experience
bathing a soothing than either showering
experience, and or tub bathing.
reduce client  Adaptive devices
aggression. extend the client’s
reach, increase speed
 Teach use of and safety, and
adaptive bathing decrease exertion and
equipment (e.g., reduce caregiver
long-handled burden (Chen et al,
brushes, soap-on-a- 2000). Follow-up
rope, washcloth teaching in the home
mitt, wall bars, tub increases device use
bench, shower and safety of bathing.
chair, commode
chair without pan in  To avoid the accident
shower) and follow and for the patient to
up in the home. practice the procedure.
 Guide and  To inform the patient
support the patient of her responsibility as
and let him perform an individual.
the procedure.
 Encourage her to  To have cooperation
take a bath and guidance coming
everyday and be from relatives.
responsible to his
physical
appearance.  Improved
 Inform the communication
relatives to help the decreases aggression
patient in doing her during bathing and
duty everyday individualizes care.
regarding his proper
hygiene.
 Enhance
communication  To provide comfort
during bathing. during feeding and
Allow the client to easy movement.
participate as able
in bathing. Smile  The need for privacy
and provide praise is fundamental for
for most
accomplishments in patients.
a relaxed manner.  Clothing that is
 Place patient in difficult to get in and
optimal position for out of may
feeding. compromise a
  Provide privacy patient’s ability to be
during dressing continent.

 Assist patient in  Mechanical problems

removing or may prohibit the
replacing necessary patient
clothing. from eating.

Collaborative:
 Assure that  Collaboration and
consistency of diet correlation of activities
is appropriate for with interdisciplinary
patient’s ability to team members
chew and swallow, increases the client’s
as assessed by mastery of self-care
speech therapist. tasks.
 Request referrals
for occupational and
physical therapy.