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NURSING CARE PLAN

Problem Identified: Lower back pain
Nursing Diagnosis: Activity Intolerance r/t functional changes accompanying the aging process as evidenced by lower back pain secondary to osteoporosis
Taxonom: Activity – Exercise Pattern
Cause Analsis: ith aging! comes gradual reduction in the speed and power of skeletal or voluntary muscle contractions and sustained muscular effort" In osteoporosis!
there#s a decrease in bone density and an increased brittleness of bone $%undamentals of &ursing by 'o(ier p" )*+," -he aging process itself causes reduction in muscle
strength and function! which can impair the ability to maintain activity" $&ursing .are Plans by /ulanick p" 0,
Cues !b"e#ti$es Nursing Inter$entions Rationale E$aluation
Sub"e#ti$e:
o -he pt" complains of
lower back pain
P 1 2tunogd adtong
sayaw3sayaw4
5 1 2murag tusukon4
6 1 2diha ra man sad
dapita4
7 1 pain scale of 0/8*
- 1 2paghuman ug
sayaw! dayon pagdayun
nako ug katulog4
o -he pt" verbali(es
2dili lang sa ko
maligo kay sakit
akoang likod4
!b"e#ti$e:
o the pt" ambulates
with assistance
o the pt" perform
A9L#s with
assistance
o with musculoskeletal
status of + $re:uires
help! supervision! or
ST!:
After ;* minutes of health
teaching and effective nursing
intervention! the significant other
$volunteer, demonstrates
understanding of the patient#s
decreased activity level as
evidenced by assisting the pt" in
carrying out activities such as
taking a bath! combing the hair!
brushing her teeth and etc"
LT!:
After + days of effective nursing
intervention! the pt" will be able to
experience less discomfort when
ambulating! transferring! or
performing other activities"
Inde%endent:
8" Establish realistic goals for
improving the patient#s activity
level! taking into account the
patient#s physical limitations
and energy level"
+" Assist the patient in
performing A9L#s"
;" <onitor vital signs before and
after ambulation"
)" Provide encouragement of the
pt" even small improvements
in his activity level"
=" Encourage the patient to
express his feelings about the
decreased energy levels that
may accompany advanced
age"
>" -each the patient about good
nutrition and the importance of
ade:uate rest"
0" -each caregivers to recogni(e
the signs of physical
overativity"
?" -each energy conserving
techni:ues such as@
o 7itting to do tasks
o .hanging positions
8" -o help improve the patient#s
:uality of life" 'eep in mind
that in some older patients!
even minimal improvements
in activity level are
noteworthy"
+" %or the client to conserve
energy"
;" -o detect cardiovascular
insufficiency
)" -o help restore self –
confidence"
=" -o enhance acceptance"
>" -o improve poor health
practices"
0" -his promotes awareness
when to reduce activity"
?" -his allows enough time so
not all work is completed in a
short periodA to avoid
teaching from
another person and
e:uipment or device
o sensory deficit
$hearing and vision,
o sedentary lifestyle
o 66 1 80 breaths per
minute $at rest, but
rises up to +; when
doing activities
o 7tump posture
often
o Pushing rather than
pulling
o 7toring fre:uently
used items within easy
reach
B" Encourage the patient to take
part in social activities"
Collaborati$e:
8" 6efer the pt" to a home health
care agency for follow – up
care"
bending and reaching"
B" -o increase stamina and
decrease social isolation"
8" -o foster the patient#s
independence"
Referen#es: &urse#s Pocket /uide 8*
th
Edition by 9oenges! pp" >= – >?
&ursing 9iagnosis >
th
Edition by 7park and -aylor! pp" =;+ – =;;
&ursing .are Plans =
th
Edition by /ulanick and <yers! pp" 0 3 8*

NURSING CARE PLAN
Problem Identified: Pruritus
Nursing Diagnosis: 6isk for Impaired 7kin Integrity r/t aging process and presence of skin allergy as evidenced by itching in both lower arms
Taxonom: &utritional – <etabolic Pattern
Cause Analsis: In aging! the skin becomes drier and more fragileA there#s a progressive losses of subcutaneous fat and muscle tissue $%undamentals of &ursing by 'o(ier
p" )*+," &ormal loss of skin elasticity accompanied by skin allergy potentiates the effects of pressure and hastens the development of skin breakown $&ursing .are Plans by
/ulanick p" 8)B,
Cues !b"e#ti$es Nursing Inter$entions Rationale E$aluation
Sub"e#ti$e:
o -he pt" verbali(es
2katol Cud kaayo na
siya! ginadili man
gud ang gabi sa
akoa4
!b"e#ti$e:
o ?* years old
o Poor skin turgor
o Loss of skin
elasticity
o Presence of skin
allergy
o Allergy feels 2rough4
o the pt" scratching the
the 2pruritic site4
o dry skin
ST!:
After ;* minutes of health
teaching! the caregiver will be able
to identify ways to maintain good
skin turgor such as applying lotion
to the pt"
LT!:
After + days of effective nursing
intervention! the pt" will be able to
maintain intact skin"
Inde%endent:
8" 9etermine age"
+" Educate the patient or
caregiver about changes to
skin caused by aging"
;" Delp the patient obtain
appropriate evaluation and
treatment of the underlying
skin condition"
)" Ese preventive skin devices
such as pillows"
=" -each the patient about the
need for good nutrition and
benefits of ade:uate vitamin
and protein intake"
>" Instruct the patient not to
scratch the 2itchy4 area"
0" 9iscuss the need to maintain
8" Elderly patient#s skin is
normally less elastic and has
less moisture! making for
higher risk of skin
impairment"
+" -o motivate the patient or
caregiver to implement a skin
care regimen" Physiologic
changes associated with
aging increases the risk of
skin breakdownA it also
leaves older patients
vulnerable to problems
associated with dry skin"
;" -o promote healing and
minimi(e complications"
)" -o avoid discomfort and skin
breakdown"
=" /ood nutrition helps maintain
ade:uate tissue nourishment!
perfusion! and oxygenation"
>" -o avoid infection and further
skin damage"
0" A daily program of skin
inspection and maintenance
will protect the older patient#s
good personal hygieneA use
nonirritating $non 3 alkaline
soap,A pat rather than rub dry
skinA inspect skin regularlyA
and recogni(e and report
signs of skin breakdown
$redness! blisters! F
discoloration,"
?" Encourage the patient or
caregiver to seek immediate
attention if skin inCury or
trauma occurs"
skin integrity"
?" -o help prevent further inCury
and conditions that may
re:uire extensive treatment"
Referen#es: &ursing .are Plans =
th
Edition by /ulanick and <yers! pp" 8)B – 8==
&ursing 9iagnosis by 7park and -aylor >
th
Edition! pp" =?8 – =?+
NURSING CARE PLAN
Problem Identified: 6isk for Imbalance Gody -emperature
Nursing Diagnosis: 6isk for Imbalance Gody -emperature r/t decreased sensitivity to thermoreceptors
Taxonom: &utritional – <etabolic Pattern
Cause Analsis: -he loss of skin receptors which takes place gradually produces an increased threshold for sensations of pain! touch! and temperature predisposes the older
adult for imbalanced body temperature $%undamantals of &ursing by 'o(ier p" )*;,"
Cues !b"e#ti$es Nursing Inter$entions Rationale E$aluation
Sub"e#ti$e:
o -he pt" verbali(es
2tugnawon man Cud
ko ug kadlawon4
!b"e#ti$e:
o ?* years old
o Poor skin turgor
o Poorly elastic skin
o 9ry skin
ST!:
After ;* minutes of health
teaching! the caregiver will be able
to express understanding of
factors that cause hyperthermia or
hypothermia such as extremes of
heat and cold"
LT!:
ithin + days of effective nursing
intervention and health teaching!
the pt" will be able to exhibit
normal body temperature of $;>"=
– ;0"+ H .,"
Inde%endent:
8" Assess the caregiver#s
knowledge and lifestyle before
teaching about hyperthermia
and hypothermia"
+" Encourage the pt" to remain
active when in a cool
environment"
;" Explain to the pt" and
caregiver why the patient
needs warm clothing in cool
climates! even indoors"
7uggest socks! nonslip house
shoes! and leg warmers"
)" .lothed the patient with
appropriate clothing"
8" -o gear the teaching plan to
the patient#s needs"
+" -o keep warm and maintain
normal metabolism"
;" -o provide warmth to
vulnerable lower extremities!
where vascular changes may
cause decreased
temperature sensation"
)" -o prevent overheating in an
older patient with faulty
receptors"
Referen#es: &ursing .are Plans =
th
Edition by /ulanick and <yers! pp" +8 – ++
&ursing 9iagnosis >
th
Edition by 7parks and -aylor! pp" =;> – =;?
NURSING CARE PLAN
Problem Identified: Glurred Iision
Nursing Diagnosis: 9isturbed 7ensory Perception $Iisual, r/t the aging process
Taxonom: 7elf – Perception/ 7elf – .oncept Pattern
Cause Analsis:
Cues !b"e#ti$es Nursing Inter$entions Rationale E$aluation
Sub"e#ti$e:
o -he pt" verbali(es!
2dili man ko maka3
klaro ug ngit – ngit!
hayag maka3klaro
man gamay4
!b"e#ti$e:
o ?* years old
o &ight blindness
o 7hrunken
appearance of the
eyes
o 7lowed blink reflex
o Looseness of
eyelids
o Less power of
adaptation to
darkness and dim
light
o .annot discriminate
colors
ST!:
After ;* minutes of health
teaching! the caregiver will be able
to understand the normal changes
in visual sensation of the pt" as
evidenced by assisting the pt" in
performing A9L#s"
LT!:
ithin + days of effective nursing
intervention! the pt" will be able to
maintain self – safety as
evidenced by not going alone at
night"
Inde%endent:
8" -each the caregiver about
normal related eye changes
$presbyopia,"
+" Instruct the caregiver to install
night – lights in the caregiver#s
room and strategically arrange
lighting"
;" Provide ade:uate light for
performing Activities of 9aily
Living $A9L#s,"
)" AdCust lighting to reduce glare
from shiny surfaces! such as
maga(ine paper and walls"
=" -ouch the patient while
communicating"
8" -o increase the caregiver#s
understanding on the
patient#s visions changes"
+" -o avoid abrupt changes in
light" Aging eyes take longer
to accommodate changes in
lighting levels"
;" -he patient over age >*
needs twice as much
illumination for close tasks as
a pt" age +*"
)" Aging eyes are more
sensitive to glare"
=" -o communicate that you#re
listening"
Referen#es: &ursing 9isgnosis <anual >
th
Edition by 7parks and -aylor pp" =0? 3 =0B