NURSING CARE PLAN

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective data:
Masakit po ang
kaliwang tuhod ko, lalo
na pag naigagalaw as
verbalized by the
patient.
Objective data:
ain scale o!
"#$%
&acial gri'ace
(uarded
'ove'ents
)rritability
*oint swelling
+lteration in co'!ort:
+cute pain related to
co'pressed nerve
endings
+!ter ,% 'inutes o!
nursing intervention,
the client will verbalize
a decrease in pain
sensation !ro' "#$% to
,#$% or below
-stablished trust
and rapport
-ncouraged
verbalization o!
!eelings about
pain
rovided co'!ort
'easures such
as touch,
repositioning and
use o! cold
co'press
-ncouraged
rela.ation
techni/ue such
as deep
breathing
e.ercises
-ncouraged
diversional
activities such as
listening to
'usic and
socialization with
others
+d'inistered
0o gain clients
cooperation
0o reduce !ear
and an.iety that
'ay contribute
to pain sensation
0o pro'ote
nonphar'acologi
cal pain
'anage'ent
0o distract
attention on pain
sensation and
reduce tension
0o reduce pain
sensation
through
distraction
0o 'aintain
acceptable level
(oal 'et, patient1s pain
sensation is reduced as
evidenced by patient1s
verbalization o! pain
scale !ro' "#$% to 2#$%.
analgesic as
ordered
o! pain
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective data:
3al! cup lang po ng
rice ang nauubos ko
kapag ku'akain ako at
di din po ako 'ahilig
ku'ain ng gulay as
verbalized by the
patient.
Objective data:
4eight loss !ro'
25kg to 2,.6kg
7M) o! $,.$
oor 'uscle tone
)'balanced nutrition:
less than body
re/uire'ents related to
!ood intake less than
89+
+!ter $ hour o! nursing
intervention, patient
will able to understand
behaviors, li!estyle
changes to regain and
'aintain appropriate
weight
-stablished trust
and rapport
+ssesses weight
and recorded
+ssessed eating
habits including
!ood pre!erences
and tolerance
-ncouraged to
choose !ood
pre!erences
-ncouraged oral
care be!ore and
a!ter 'eal
+dvised to
continue in
taking !ood
supple'ents
such as
0o gain clients
cooperation
0o established
baseline
para'eters
0o appeal to
patient1s likes
and dislikes
0o sti'ulate
appetite
0o avoid poor
oral hygiene that
'ay alter
appetite
0o 'eet nutrients
that are not
!ound in
patient1s usual
(oal 'et, patient was
able to understand
behaviors, li!estyle
changes to regain and
'aintain appropriate
weight as evidenced by
verbalization o! patient
to increase his !ood
intake
'ultivita'ins
and 'inerals
diet
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective data:
:ahihirapan po akong
igalaw ang 'ga
kasukasuan ko as
verbalized by the
patient.
Objective data:
Sti;ness on the
joints
Swelling o! the
joint
<i'ited range o!
'otion
ain on the joints
during e.ertion
=ncoordinated
'ove'ents
)'paired physical
'obility related to
'usculoskeletal
i'pair'ents
+!ter $ hour o! nursing
intervention, patient
will able to
de'onstrate and
indenti!y techni/ues or
behaviors that enable
resu'ption o! activities
-stablished
trusts and
rapport
)nstructed to
support a;ected
body parts or
joints using
pillows, !oot
supports and
bandage
-ncouraged rest
in between
activities
-ncouraged
participation in
sel!>care
-ncouraged
range o! 'otion
e.ercises
-ncouraged
ade/uate intake
o! ?uids and
nutritious !ood
0o gain clients
cooperation
0o 'aintain
position o!
!unction and
reduce risk o!
pressures
0o reduce !atigue
0o enhance sel!>
concept and
sense o!
independence
0o avoid
co'plication o!
the a;ected side
ro'otes well>
being and
'a.i'izes
(oal 'et, patient was
able to de'onstrate
and identi@ed
techni/ues or behaviors
that enable resu'ption
o! activities as
evidenced by patient
per!or's active and
passive range o! 'otion
e.ercises
energy
production
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective data:
9i ko 'agawa ng
'aayos yung dapat
kong gawin dahil sa
kalagayan ko as
verbalized by the
patient.
Objective data:
=ncoordinated
'ove'ents
Sti;ness o! joints
ain during
e.ertion in the
joints
<i'ited range o!
'otion
oor 'uscle tone
+ctivity intolerance
related to
'usculoskeletal
i'pair'ents as
'ani!ested by joint
swelling and poor
'uscle tone
+t the end o! the shi!t,
patient will able to
report increase in
activity tolerance
-stablished
trusts and
rapport
)nstructed to
adjust activities
-ncouraged to
increase activity
or e.ercise levels
gradually
-ncouraged rest
in between
activities
rovided positive
at'osphere
rovided co'!ort
0o gain clients
cooperation
0o prevent over
e.ertion
0o conserve
energy
0o conserve
energy
0o 'ini'ize
!rustration and
rechannel energy
0o enhance
ability to
participate in
(oal 'et, patient was
able to de'onstrate
increase in activity
tolerance as evidenced
by patient able to
trans!er !ro' bed to
chair without
assistance
'easures and
relie! o! pain
activities
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective data:
:ahihirapan po akong
'aligo as verbalized
by the patient.
Objective data:
)nability to wash
body and get
bath supply
9iAculty to put
clothing
9iAculty in
handling eating
utensils
Sel!>care de@cit related
to disco'!ort
+!ter the shi!t, the
patient will able to
per!or' sel!>care
activities within level o!
own ability
-stablished
trusts and
rapport
ro'oted
patients
participation in
activities
+ssisted patient
in 'eeting his
needs i! he is
unable to 'eet
own needs
0o gain clients
cooperation
0o enhance sel!
reliance and
pro'ote
independence
ersonal care
assistance is part
o! nursing care
and should not
be neglected
while pro'oting
and integrating
sel!>care
independence
(oal 'et, patient was
able to per!or' sel!>
care activities within
nor'al level o! own
ability as evidenced by
patient appears clean,
neat, tidy and well
groo'ed
rovided !or
co''unication
a'ong those
who are involved
in caring and
assisting !or the
patient
-ncouraged
energy>saving
behaviors such
as sitting instead
o! standing as
possible
-nhances
coordination and
continuity o! care
0o conserve
energy while
per!or'ing sel!>
care activities
Risk factors Diagnosis Planning Interventions Rationale Evaluation
<i'ited ?uid intake
&re/uent bleeding
-cchy'osis
3e'arthrosis
8isk !or de@cient ?uid
volu'e
+!ter $ hour o! nursing
interventions, the
patient will able to
understand behaviors
or li!estyle changes to
prevent develop'ent
o! ?uid volu'e de@cit
-stablished
trusts and
rapport
Monitor intake
and output
+ssessed skin
turgor and oral
'ucous
0o gain clients
cooperation
0o ensure
accurate picture
o! ?uid status
0o 'onitor signs
o! dehydration
(oal 'et, patient
understood behaviors
or li!estyle changes to
prevent develop'ent o!
?uid volu'e de@cit as
evidenced by patient1s
oral ?uid intake is
increased !ro' ,6'l#hr
to "%'l#hr
'e'brane
-ncourage to
increase oral
?uid intake
:oted client1s
age, current level
o! hydration and
'entation
+d'inister )B
?uids as
prescribed
0o pro'ote
hydration
rovides
in!or'ation
regarding ability
to tolerate
?uctuations in
?uid level and
risk !or creating
or !ailing to
respond to
proble'
0o deliver ?uids
and pro'ote
hydration