NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS

Impaired physical mobility related to musculoskeletal impairment.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Nagagalaw ko naman ang kamay ko pero limitado lang, as verbalized by the patient.

Objective: Limited range of motion of right arm Slow movement Completely dependent to mother

After 4 hours of nursing intervention, the patient will be able to verbalize understanding of situation/ risk factors and individual treatment regimen and safety measures.

Independent: Provide regular skin care. Schedule activities with adequate rest periods during the day. Encourage participation in self-care, occupational/ diversional activities. Provide for safety measures as indicated by individual situation, including environmental management/ fall prevention. Encourage adequate intake of fluids/ nutritious foods. Demonstrate use of adjunctive To include pressure area management To reduce fatigue

To enhance self-concept and sense of independence

After 4 hours of nursing intervention, the patient had verbalized understanding of situation/ risk factors and individual treatment regimen and safety measures.

To promote well being and maximizes energy production To promote independence and enhances

devices.

safety

Dependent: Administer medications prior to activity as needed for care relief. Collaborative: Assist with treatment of underlying condition causing pain and/or dysfunction. Consult with physical/ occupational therapist as indicated.

To develop individual exercise/ mobility program and identify appropriate adjunctive devices

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING CARE PLAN

INTERVENTION

RATIONALE

EVALUATION

Subjective: Hindi na ko makatulog ng walong oras, as verbalized by the patient. Objective: Frequent yawning Restlessness

Disturbed sleep pattern related to noise, lighting, ambient temperature, humidity and noxious odors.

After 4 hours of nursing intervention, the patient will be able to identify individually appropriate interventions to promote sleep.

Independent: Provide quiet To establish environment optimal rest and comfort patterns measures in preparation of sleep. Recommend limiting intake of chocolate and caffeine especially prior To promote to bedtime. wellness Assist client to develop individual program of relaxation. Demonstrate techniques. To aid in stress control Explore other sleep aids. Advise patient to think relaxing thoughts when in bed. Dependent: Administer pain medication ( if required) 1

After 4 hours of nursing intervention, the patient had identified individually appropriate interventions to promote sleep.

hour before sleep.