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NURSING CARE PLAN

Cues Nursing

Diagnosis

Analysis Goal and

Objectives

Nursing

Interventions

Rationale Evaluation

Subjective:

The client

verbalized

Nahihirapan

ako sa

kalagayan ko

kasi hindi ako

makagalaw

ng maayos

Objective:

Difficulty

turning

Limited range

of motion

Actual

Diagnosis:

Impaired physical

mobility r/t

musculoskeletal

impairement as

evidenced by

imposed

immobility bytraction

Fracture is a

break in the

continuity of the

bone.

Immobilization is

needed to correct

the position and

alignment of the

bone.Immobilization

may be

accomplished by

external and

internal fixation.

Methods of

external fixation

include bandages,

casts, splints, andtraction.Suzanne C,Smeltzer, RN, EdD,

FAAN, Brenda G. Bare,

RN, MSN Brunner &

Suddarths Medical-

Surgical Nursing 10th

ed.

Goal: By May 31

2014 the client will

be free of traction

and will be able to

walk at least 20 ft

with the use of the

walker.

Objective: After 8

hours of duty, the

client will:

K: Learn to

correctly

reposition herself

on a regular

schedule.

Learnactive/passive

range of motion

exercises of

unaffected and

affected extremity

Learn diversional

1. Encourage

participation in

diversional activities.

Maintain stimulating

environment, e.g.,

radio, TV,

newspapers,

personal

possessions/pictures,clock, calendar, visits

from family/friends.

2. Instruct patient

in/assist with

active/passive ROM

exercises of affected

and unaffected

extremities.

3. Encourage use of

1. Provides

opportunity for

release of energy,

refocuses

attention,

enhances patients

sense of self-

control/self-worth,

and aids inreducing social

isolation.

2. Increases blood

flow to muscles

and bone to

improve muscle

tone, maintain

joint mobility;

prevent atrophy

and calcium

resorption from

disuse

3. Facilitates

Effectiveness:

Was the

client able to

identify and

demonstrate

interventions

that will

relieve

present

condition?

Yes?

No?

Why?

Where the

interventions

enough to

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activities

Learn the use of

overhead trapeze

Learn appropriate

foods for faster

healing

S: Demonstrate

and practice

active range of

motion exercises

Demonstrate and

practice the use of

overhead trapeze

A: Encourage

participation in

diversional

activities

Encourage self-

care activities

trapeze

4. Assist

with/encourage self-

care activities (e.g.,

bathing, shaving).

7. Reposition

periodically

8. Provide diet high

in proteins,carbohydrates,

vitamins, and

minerals

9. Increase the

movement during

hygiene/skin care

and linen

changes; reduces

discomfort of

remaining flat in

bed.

4. Improves

muscle strength

and circulation,

enhances patient

control in situation,

and promotes self-directed wellness.

7. Prevents skin

complications

8. In the presence

of musculoskeletal

injuries, nutrients

required for

healing are rapidly

depleted

9. Adding bulk to

stool helps

prevent

solve the

clients health

problem?

Yes?

No?

Why?

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amount of

roughage/fiber in the

diet.

constipation.