Nursing Care Plan #

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Acute pain r/t Short term: Independent:
numbness and Short term:
“Hawoy, After 30mins-1
sakitgyudugmuragn tingling sensation in 1. Provide 1. To promote
the lower hour of nursing comfort non- After 1hour of
aaygapanusoksaak intervention the nursing
otiiltaposmudaganp extremities measures pharmacologica
radiating to hips client will be able such as: l pain interventions the
adulongsaakolikodu to: client was able to :
g hips” as and lower back touch, management
1. Reduce pain repositioning 1. Express sense
verbalized by the scale of 8/10 to of controlled
patient. ,nurses
0-3/10. presence. relief from the
2. Verbalize pain and
feeling of relief 2. Maintain a 2. To not discomfort.
from pain and quiet aggravate the
discomfort. environment 2. Reduced pain
Objective: pain and
and provide scale to 3/10
discomfort.
Facial grimacing calm from 8/10.
Long term: activities
Protective gestures Long term:
After 4-5 hours of 3. To divert
noted nursing intervention 3. Provide attention and After 5 hours of
magazines nursing
Increased BP the client will be and books promote mental intervention the
130/90 able to: and teach on health. client was able to:
1. Demonstrate how to do 1. Perform
use of focused relaxation
Pain scale 8/10 relaxation breathing techniques
skills, properly and do
techniques and 4. Encourage diversional
diversional verbalization activities.
4. To evaluate
activities. of feelings
coping abilities
about the
and identify
pain.
additional
concerns.

5. Provide
diversional 5. To help relieve
activities the pain.
6. Reposition
client every 2 6. Promote
hours. healing,
comfort,
relaxation and
circulation.
Collaborative:

1. Administer
medication 1.To relieve the
(particularly pain.
analgesics) as
prescribed.
 Nursing Care Plan #

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Deficient Short term: Independent: Short term:
“Mag linkod-linkod diversional activity 1. Explain to the 1. To encourage
r/t insufficient After 30mins-1 After 30mins-1
lang, storya-storya hour of nursing patient the activity the patient to have hour of nursing
sa akong asawa ug diversional activity to be done and its his full participation
intervention the intervention the
tan aw sa palibot client will be able importance. in doing the an client was able to:
kay wala man tv to: activity. 1. Engage in
diri” as verbalized 1. Engage in appropriate
by the patient. appropriate activities with
2.Start from basic 2.Help patient
activities with determine his limitations
ADLs then
limitations capacity in doing a 2. Set schedules
gradually
2. Set schedules certain activity, it for the activities
Objective: progresses to a
for the activities also gain his self to be done.
Appears bored more complex
to be done. esteem.
one.
Fatigued
Long term:
Long term:
3.Let the patient 3. To determine After 3-5 hours of
After 3-5 hours of verbalize what he what exact activity nursing intervention
nursing intervention feels and wants in the patient wants the client was able
the client will be an activity to do and enjoyed to:
able to: the most.
1. Independently 4. Encourage the 4. To promote 1. Independently
perform the patient to set a further stimulation perform the
appropriate certain schedule and engagement appropriate
routine activities for the next in different kinds routine activities
needed. activity. of activities needed.
2. Gain more needed by the 2. Gain more
confidence in patient confidence in
performing the performing the
appropriate 5. Provide change appropriate
activities. of scenery 5. To provide activities.
positive sensory
stimulation,
reduce sense of
boredom.
Collaborative:
1. Make
appropriate
1. To promote
referrals to
further stimulation
available
and engagement
support
in different kinds of
groups,
activities
hobby clubs,
service
organization.
 Nursing Care Plan #

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Short term: Independent: Short term:
“ga lisod nakog Self-care deficit: After 2-3 hours of After 2-3 hours of
buhat sa mga gina bathing, dressing, nursing 1. Assist client in 1.An appropriate nursing
buhat nako sauna, toileting, mobility intervention the meeting needs level of assistance intervention the
di nako ka adto CR, client will be able when he is unable in activity can client was able to:
di na kabaklay ug to: to meet own prevent injuries 1. Perform self
tarong na wala mag 1. Perform self needs. and prevent care activities
assist ug di nako care activities frustrations. within level of
kabalik sa ako within level of own ability.
trabaho” as own ability.
verbalized by the 2. Develop plan of 2.Helps prevent
2. Demonstrate
patient. care appropriate fatigue and be able
2. Demonstrate techniques and
to individual to comply with
techniques and lifestyle changes
situation via given activities.
Objective: lifestyle changes to meet self-care
to meet self-care scheduling needs
Dependent on ADL: activities for the
needs.
mobility, hygiene, client(passive Long term:
toileting and and active ROM
dressing exercsies)
Long term: After 2-4 hours of
nursing intervention
Limited movements After 2-4 hours of 3. Encourage 3.Enhance clients the client was able
noted nursing intervention independence capabilities and to:
the client will be but intervene promote 1. Participate in
able to: when client independence. activities that will
1. Participate in cannot perform promote his level
activities that will of functioning
promote his level and learn and
of functioning 4.Involve SO in 4.Invovling clients recall his
and learn and providing care for SO can help in previous
recall his the client clients recovery capabilities.
previous when the nurse
capabilities. isn’t in the
Collaborative: bedside.

1. Review
instructions to 1. Involving other
other health care health care
team on providing members will
positive make the client
reinforcement for feel valued, and
all activities done will also help in
by the client, and clients recovery.
to encourage
independence as
appropriate.