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Saint Joseph College Institute of Health Sciences Cavite City NURSING CARE PLAN Name: Address: Impression: Cues/Evi

ence s Subje tive: nahihirapan akong gumalaw !bje tive: " presen e of #ound " de reased mus le strength " limited range of motion " inability to perform a tivities limited range of motion$ slo#ed movements and relu tan e to attempt movement Impaired physi al mobility
REFERENCE: Tetbook of Medical-

Age: Room No: ASSESSMENT Nu!sin" #ia"nosis A tivity intoleran e related to damage to tissues$ as manifested by " presen e of #ound " de reased mus le strength " limited range of motion " inability to perform a tivities 'ain Inflammation pro ess triggered Nerve ending ompression development in range of motion* evident strength* mus le PLANNING Nu!sin" O$%ective At the end our of ("hour shift$ the patient)s ability to perform fine and gross motor a tivities #ill in rease as eviden ed by:

Sex:

Date of Admission:

Scientific Rationale Surgery$ CS delivery %rea&ing in the ontinuity of the s&in

IMPLEMENTATION Nu!sin" O! e!/Action Scientific Rationale

EVALUATION

/- Determine fa tors that ontribute to immobility$ su h as the presen e of #ound and patient)s spa e that may ontribute to immobility0- Determine extent of immobility in relation to fun tional level s ale 1- Note emotional or behavioral responses to problems of immobility2- Assess patient)s ability to perform AD3s noting reports of #ea&ness$ fatigue and diffi ulty in a omplishing tas&-

/- 4o be informed about the situations that may restri t movements-

At the end of our ("hour shift$ nursing intervention$ the goal #as met as eviden ed by: - development in range of motion* evident mus le strength* oordination in movement and patient verbali+es: ,Na&a&agala# na a&o ng maayos-.

0- 4o assess fun tional ability-

oordination in movement and patient verbali+es: ,Na&a&agala# na a&o ng maayos-.

1- 5eelings of frustration or po#erlessness may impede attainment of goals2- 4o provide appropriate nursing are-

urgical #$%&

Nur!ing"

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6- 7onitor laboratory results li&e 8gb- 9 8 t-

6- 4o identify the extent of defi ien y 9 for better treatment plan:- 4he longer the patient remains immobile$ the greater the level of debilitation that #ill o ur<- 4o have enough energy to perform AD3(- to give se urity and omfort-

:- ;n ourage and fa ilitate early ambulation and other AD3s #hen possible<- Advise patient to in rease oral fluids and alori inta&e(- 'rovide safety measures* using pillo#s to support body part$ fa ilitate enough spa e for patient$ et =- Assist the patient #hen she tries to perform an a tivity/>- !bserve for hanges after doing the nursing interventions

=- In order to prevent injury and it gives en ouragement to move further/>- 4o monitor for progress and identify additional needs for nursing are-