NURSING CARE PLAN

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired physical Trauma At the end 6hrs. of > Determine > To identify After 6hrs. of
mobility related to nurse-patient diagnosis that contributing nurse-patient
(Vehicular
loss of integrity of interaction and contributes to factors interaction and
accident)
“Hindi ko bone structures intervention, the immobility. intervention, the
maigalaw ung (fracture) patient will: patient has:
binti ko ”, as
Fracture of the left a) Verbalized
verbalized by the > note situations
leg > cause it may understandin
patient a) Verbalize such as fractures
restrict movement g of the
understanding
situation and
of the situation
bleeding from individual
Objective: and individual > determine the
damaged ends of > to assess treatment
treatment degree of immobility
bone and functional mobility regimen and
regimen and in relation to
surrounding tissue safety
>limited range of safety suggested scale measures.
motion measures.
b) Participated
b) Participate in
in ADLs and
stimulates ADLs and > determine desired
inflammatory desired
>slowed presence of activities
response activities > to assess
movement complications c) Maintained
c) Maintain related to immobility presence of position of
position of (pneumonia, complications function and
increased capillary function and elimination
>limited ability to skin integrity
permeability skin integrity problems,decubitus)
perform gross as evidenced
as evidenced
and fine motor by absence
by absence of
of decubitus
fluid and cellular decubitus
> Assist client ulcers
exudation ulcers
> with cast on left reposition self on a d) Maintained
d) Maintain and
leg regular schedule. and
increase
increased
pain strength and
> to promote strength and
function of
optimum level of function of
>Functional affected part.
function and affected part.
Level: 3
impaired physical prevent
 mobility > Support affected complications
body part using
pillows.
> to maintain
position and
function and
reduce risk of
pressure ulcers.
> Encourage
adequate intake of
fluids/nutritious > It promote well-
foods being and
maximizes energy
production

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for infection Trauma At the end of the >Note risk factor for >To assess After 6hr nurse-
related to wound 6hr nurse-patient occurrence of infection causative/ patient interaction
(Vehicular
secondary to interaction and contributing and intervention
accident)
fracture intervention the factors the patient has :
patient will:

Fracture of the left

>To assess for a) identified
leg
a) Identify >Observe for localized infected sites interventions to
interventions to signs of infection prevent/reduce
prevent/reduce risk of infection
bleeding from risk of infection . >A first line
Objective: damaged ends of b) Achieved
>Stress proper hand- defense against
bone and b) Achieve timely timely wound
(+) presence of hygiene by all healthcare-
surrounding tissue wound healing; healing; be
wound caregivers bet. associated
be free of Therapies/clients. infections free of purulent
purulent drainage or
V/S taken as broken skin drainage or >To reduce erythema;
follows: erythema; bacterial
(wound)
colonization
Temp:
c) Be afebrile as >Recommend routine c) Been afebrile
RR: evidenced by or body shower/scrub as evidenced
Risk for infection the normal when indicated >To prevent by the normal
PR: V/S. infection V/S.
BP:
>Change surgical or
other wound
dressings, as
indicated, using
proper technique for
changing or disposing
of contaminated
materials

>Review individual >To promote

nutritional needs, wellness.