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NURSING CARE PLAN
 
ASSESSMENT NURSINGDIAGNOSISINFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:“Hindi siyamakatagilidsumasakit dawung bali niya samay bewangkapaggumagalaw” asverbalized by thesn of the patient.Objective:
Impairedability to turnside to side
Impairedability tomove fromsupine tositting viseversa.
(+) presenceof pelvicfracture
(+) Generalweakness
Tremorsnoted on leftarm andhands> Impaired bedmobility relatedto pain secondarytomusculoskeletalimpairment.Trauma(slipping) bone fracture at pelvic boneDisruptions of  periosteum and blood vesselsDestruction if tissueBleeding occursPainImpaired bedmobilityAfter the rotationand nursingintervention thesignificant other of the patientwill:a.Verbalizeunderstandingof thesituation /risk factors,individualtherapeuticregimen andsafetymeasures. b.Demonstratetechniques/ behaviors thatwill enablesaferepositioningc.Maintain position of function andskin integrityof the patientas evidenced by absence of contractures,foot drop,decubitus, etc.
determinediagnoses thatcontribute toimmobility (e.g.fractures,hemi/para/tetra/quadripegia)
 Note individualrisk factors andcurrent situation,such pain, age,generalweakness,debilitation
Determine perceptual/cognitiveimpairment tofollow directions
Determinefunctional levelclassification
 Note presence of complicationsrelated toimmobility
Observe skin for reddenedareas/shearing.Provideappropriate pressure to relief 
Provide regular skin care if appropriate
Assist withactivities of hygiene,toileting,
To identifycausative/contributingfactors.
To assess patientsfunctionalability
To reducefriction,maintain safeskin/tissue pressures andwick awaymoisture
To preventcomplications
To promoteoptimal levelof functioningAfter the rotationand nursingintervention thesignificant other of the patientwill:a.Verbalizeunderstandingof thesituation /risk factors,individualtherapeuticregimen andsafetymeasures. b.Demonstratetechniques/ behaviors thatwill enablesaferepositioningc.Maintain position of function andskin integrityof the patientas evidenced by absence of contractures,foot drop,decubitus, etc.
 
ASSESSMENT NURSINGDIAGNOSISINFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:“Hindi namakagalaw sinanay simulanung na-strokesiya ” asverbalize by theson of the patientObective:
(+) General> Impaired physicalmobility relatedto Neuromuscular impairmentHypertension
ˇ
Occlusion withinvessels of the brain parenchymaˇDisruption of bloodsupply in the brainareaˇTissue and cellnecrosisˇAfter therotation andnursingintervention the patient will:a.Maintain position andfunction andskinintegrity asevidenced by absence
Determinediagnosis thatcontributes toimmobility(e.g. fractures,hemi/ para/tetra/quadriplegia)
Assessnutritionalstatus and S/Oothers report of energy level.
To identifycausative/contributingfactors.After the rotationand nursingintervention the patient will:c.Maintain position andfunction andskin integrityas evidenced by absence of contractures,foot drop,
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