Assessment Nursing Rationale Goal/Objectiv Intervention Rationale Evaluation

Diagnosis es

Subjective Partial Self Body image, Objectives: - Assess - This will

Cues: care deficit hygiene, and client’s self serve as a After 1
related to other self After 1hour of care need baseline data hour of
“Nung nakaraang inability to practices are nursing as to what the nursing
dalawang araw perform daily influenced by intervention, client’s level of interventio
pa nung huli activities the people or the client will self care need. n, the client
akong naligo. peers around a be able to meet was able to
Gustong gusto ko school aged self care need: - To provide meet self
na maligo e.” child. This is a bathing. - Assess the overall care needs:
stage wherein a client’s data on what bathing.
Objective Cues: child based his physical self care need
- presence norms to that of condition should be
of around him. relating to given to the
skeletal hygiene. client.
balancing
traction
-To provide
- Provide self comfort
care need:
bed bath.
-To enhance
- Encourage independence
client to do
self care.
ASSESSMENT DIAGNOSIS RATIONALE PLAN INTERVENT RATIONALE EVALUATION
ION

Subjective: Partially Femoral After 4 hours Assess for To maintain After the
“Nahihirapan impaired fractures of nursing correct position good body nursing
akong physical are seen to intervention, of traction and alignment intervention,
gumalaw dahil mobility those the patient will alignment of when the patient was
ditto sa bali sa related to people who be able to bones mechanical able to
buto ko” musculoskelet have been maintain devices are maintain
al disorder involved in position of Maintain limbs used position of
Objectives: (femural a motor function with in functional function and
fracture) and vehicle maximum alignment. This will exerted
- Limited external crash or mobility within Support feet in prevent maximum
ROM device who have the dorsiflexed footdrop mobility within
of left lower (skeletal fallen from a therapeutic position the therapeutic
extremity traction) high place. limits of limits of
- Presence of traction. Perform traction.
restrictive passive and
device active ROM Enhances
(skeletal exercises on circulation
traction) extremities and maintains
- Insertion of joints, using muscle tone
Steinmann’s slow smooth and joint
pin movements on mobility and
the unaffected prevents
body parts disuse
contractures
and muscle
Encourage use atrophy.
of trapeze
 Strengthen
shoulders an
arm muscles
necessary for
Instruct and safe
assist in positioning
position and
changes and mobilization
transfers.

Encourages
active
Keep side rails participation
up and bed in while
low position preventing
stress on
fractured bone

This promotes
a safe
environment.