VII.

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: High Risk for Short-Term Goal • Monitor peripheral • To assess baseline Short-Term Goal
• “madalas Injury R/T After 3 hours of pulses and vital signs, data After 3 hours of
mamanhid ang increased nursing intervention, especially the heart rate nursing intervention,
aking mga kamay neuromuscular the client will be every hour to every four the client verbalized
at paa ko, pati na irritability able to verbalize hours depending on the understanding of
rin ang aking resulting from understanding of client’s condition. • To assist client to individual factors
labi”, as hypocalcemia individual factors • Provide information reduce or correct that contribute to
verbalized by the that contribute to regarding individual risk possibility of injury
patient named Mr. possibility of injury disease/condition that factor. and take steps to
Sy, 35 yrs.old. and take steps to may result in increased correct situations.
correct situations risk of injury. Goal was met
Objective: • Evaluate individual’s
• Anxious Long-Term Goal response to violence in • May enhance Long-Term Goal
• Irritability After 7 days of surroundings disregard for After 7 days of
nursing intervention, nursing intervention,
• Dry, sparse hair • If the client is own/other’s
the client will be free safety. the client had been
• Rough skin from injury
receiving intravenous
free from injury
calcium, the nurse
associated with associated with
BT: 36.7 C needs to monitor the
calcium deficit, as calcium deficit, as
PR: 65 bpm IV site for infiltration
evidenced by no falls evidenced by no falls
RR: 18 cpm or phlebitis every hour • Calcium chloride
or near falls and no or near falls and no
pathologic fractures. •
BP: 120/70 mmHg Symptomatic is extremely
pathologic fractures.
hypocalcemia should irritating to the
Goal was met
be assessed by testing subcutaneous
of the Chvostek’s and tissue.
Trousseaus’ signs. • To check for
• The serum calcium increased
level should be neuromuscular
closely monitored and excitability and
changes reported. tetany.