NURSING CARE PLAN

Assessment Nursing Planning Implementation Rationale Evaluation

Diagnosis
Subjective: Short Term: Independent: After 1 hour of
Disturbed nursing
Gabinhod gyud sensory At the end of the - Crossing the legs intervention, the
usahay ang akong perception next 1 hour, the 1. Instructed to avoid can put pressure client:
kamot og tiil labi na related to client will be able crossing of legs or on the Peroneal
kung mag sige ra electrolye to: putting one leg over nerve behind the
kog higda., as imbalance the other. knee, which Verbalized the
verbalized by client. supplies sensation understanding
to the lower legs of maintaining
Verbalize and feet. Crossed safety with
awareness of legs might skew the ambulation and
sensory needs reading by balance, active
Objective: and presence temporarily raising range of motion
of overload. your blood exercises
2. Kept legs in good pressure. performed.
Age: 73 years identify position on pillows. (Hammond, C.,
old methods and Identifird ways
2015)
modify - A comfortable to reduce
external positon will help stress on legs
factors that provide such as
contribute to 3. Evaluated sensory opportunities for avoiding to
Reported alterations awareness such as relaxation the cross legs and
numbness and abilities. stimulus to hot and muscles optimally. positioning legs
tingling sensation cold, dull or sharp, on a pillow.
felt rarely. mobility and function - To note whether
Ankle and leg Long Term: of legs; check for response is
edema noted. At the end of 2-4 pulse of extremities appropriate to After 2-4 hours of
Generalized hours, the client stinlmulus, nursing
weakness and will be able to: immediate or intervention, the
 fatigue noted. 4. Placed client's need delayed. client:
Pale exremities Maintain usual and essentials within
noted. level of reach and adjusted
Skin is cool to cognition. position as preferred. - Energy-saving demonstrated
touch. Be free of techniques help the non-
injury. client exert less pharmacologica
5. Provided safety effort and thus l ways to
measures such as lessen stress on reduce stress
assisting in walking client. on legs.
and raising side rails Pulse on
as needed. - To promote safety extremities
of client; Aid in present on both
6. Assisted in maintaining legs.
ambulation balance. Edema still
noted.
7. Performed active
Range of motion - To enhance
(ROM) balance.

- To maintain and
increase muscle
strength and help
Dependent/ keep joint problems
Collaborative: and contractures
from developing.

1. Discussed with the

family members on
the plan of care for
client as much as - Enhances
possible to promote commitment to and
the client's safety and continuation of
 assist with client's plan, optimizing
activities of daily outcomes.
living. - To achieve maximal
2. Collaborate with other gains in function
health team members and psychosocial
in providing well-being.
rehabilitative
therapies and drug
therapy.