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NURSING CARE PLANASSESSMENT NURSINGDIAGNOSISINFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:
“Hindi komaigalaw ungbinti ko ”, asverbalized by thepatient
Objective:
>limited range of motion>slowedmovement>limited ability toperform grossand fine motor > with cast on leftleg>FunctionalLevel: 3Impaired physicalmobility related toloss of integrity of bone structures(fracture)Trauma(Vehicular accident)Fracture of the leftlegbleeding fromdamaged ends of bone andsurrounding tissuestimulatesinflammatoryresponseincreased capillarypermeabilityfluid and cellular exudationpainimpaired physicalAt the end 6hrs. of nurse-patientinteraction andintervention, thepatient will:a)Verbalizeunderstandingof the situationand individualtreatmentregimen andsafetymeasures.b)Participate inADLs anddesiredactivities
c)
Maintainposition of function andskin integrityas evidencedby absence of decubitusulcersd)Maintain andincreasestrength andfunction of affected part.> Determinediagnosis thatcontributes toimmobility.> note situationssuch as fractures> determine thedegree of immobilityin relation tosuggested scale> determinepresence of complicationsrelated to immobility(pneumonia,eliminationproblems,decubitus)> Assist clientreposition self on aregular schedule.> To identifycontributingfactors> cause it mayrestrict movement> to assessfunctional mobility> to assesspresence of complications> to promoteoptimum level of function andpreventAfter 6hrs. of nurse-patientinteraction andintervention, thepatient has:a)Verbalizedunderstanding of thesituation andindividualtreatmentregimen andsafetymeasures.b)Participatedin ADLs anddesiredactivities
c)
Maintainedposition of function andskin integrityas evidencedby absenceof decubitusulcersd)Maintainedandincreasedstrength andfunction of affected part.
 
mobility> Support affectedbody part usingpillows.> Encourageadequate intake of fluids/nutritiousfoodscomplications> to maintainposition andfunction andreduce risk of pressure ulcers.> It promote well-being andmaximizes energyproduction
ASSESSMENT NURSINGDIAGNOSISINFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:Objective:
(+) presence of woundRisk for infectionrelated to woundsecondary tofractureTrauma(Vehicular accident)Fracture of the leftlegbleeding fromdamaged ends of bone andsurrounding tissueAt the end of the6hr nurse-patientinteraction andintervention thepatient will:
a)
Identifyinterventions toprevent/reducerisk of infection
b)
Achieve timelywound healing;be free of purulent>Note risk factor for occurrence of infection>Observe for localizedsigns of infection.>Stress proper hand-hygiene by allcaregivers bet.Therapies/clients.>To assesscausative/contributingfactors>To assess for infected sites>A first linedefense againsthealthcare-associatedinfectionsAfter 6hr nurse-patient interactionand interventionthe patient has :a)identifiedinterventions toprevent/reducerisk of infection
b)
Achievedtimely woundhealing; befree of purulentdrainage or 
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