NURSING CARE PLAN

Nursing Diagnosis: Risk For Infection r/t spanning external fixator; percutaneous suprapubic cystostomy; transection of ulnar artery

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE: Short term objective: 1. Assessed signs and symptoms 1. Fever may indicate infection. Short term objective:
of infection especially temperature.
 Presence of spanning After 8 hours of nursing After 8 hours of nursing
external fixator intervention, the patient will intervention, the patient
2. Emphasized the importance of hand 2. It serves as a first line of defense
 Presence of verbalize understanding of
washing technique.
verbalized understanding of
against infection.
percutaneous causative and risk factors causative and risk factors
suprapubic cystostomy and will identify and identified interventions
3. Maintained aseptic technique when 3. Regular wound dressing promotes
 Transection of ulnar interventions to prevent and
changing dressing/caring wound
to prevent and reduce risk
fast healing and drying of wounds.
artery reduce risk of infection. of infection.
 BP: 120/70 4. Kept area around wound clean and 4. Wet area can be lodge area
 Temp: 37.2 dry. of bacteria
 PR: 82 Long term objective: Long term objective:
 RR: 22 5. Emphasized necessity of taking 5. Premature
After 4 days of nursing After 4 days of nursing
antibiotics as ordered. discontinuation of treatment when
intervention, the patient will intervention, the patient
demonstrate techniques, client begins to feel well may result demonstrated techniques,
lifestyle changes to promote in return of infection. and changed lifestyle to
safe environment and would promote safe environment
achieve timely wound and achieved timely wound
healing; and would be free healing; and would be free
of any signs and symptoms of any signs and symptoms
of infections. of infections.

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Nursing Diagnosis: Impaired Physical Mobility r/t musculoskeletal impairments

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE: SHORT-TERM OBJECTIVES: 1. Noted factors affecting current 1. Identifies potential impairments SHORT-TERM OBJECTIVES:
situation (e.g surgery, fractures, and determines types of
 Pt is immobile due to After 8 hours of nursing After 8 hours of nursing
tubing). interventions needed to provide
the presence of external intervention, the patient intervention, the patient
2. Assessed client’s developmental level, for client’s safety.
fixator and would be able to verbalize was able to verbalize
motor skills, ease and capability of 2. To determine presence of
percutaneous understanding of situation understanding of situation
movement, posture, and gait. characteristics of client’s unique
suprapubic cystostomy and individual treatment and individual treatment
3. Assessed degree of pain, listening to impairment to guide choice of
catheter regimen and safety regimen and safety
clients description about manner in interventions.
 Muscle grade of 3/5 procedures.
which pain limits mobility. 3. To determine if pain management
procedures.
 Facial grimace when 4. Assessed nutritional status and can improve mobility.
trying to move client’s report of energy level. 4. Deficiencies in nutrients and water,
LONG-TERM OBJECTIVES: 5. Determined degree of immobility in electrolytes, and minerals can LONG-TERM OBJECTIVES:
SUBJECTIVE:
relation to 0-4 scale, noting muscle negatively affect energy and
After 4 days of nursing After 4 days of nursing
 “Sakit akong likod og dili tone and strength, joint mobility, activity intolerance.
intervention, the patient intervention, the patient
ko kalihok tungod sa cardiovascular status, balance and 5. Identifies strengths and deficits.
would be able to participate was not able to participate
akong kamot og kini endurance. 6. To note any incongruencies with
in ADLs and desired in ADLs and desired
(percutaneous 6. Observed movement when client is reports of abilities
activities; maintain position activities; has not
suprapubic catheter)” as unaware of observation 7. Feelings of frustration or
of function and skin integrity maintained position of
verbalized by the 7. Noted emotional/behavioral powerlessness may impede
as evidenced by absence of function and skin integrity
patient. responses to problems of immobility. attainment of goals.
contractures, footdrop, as evidenced by absence of
 Pt reported back pain 8. Assisted with treatment of underlying 8. To maximize the potential for
debiticus and so forth. contractures, footdrop,
with a pain scale of condition causing pain and/or mobility and function.
debiticus and so forth.
10/10. dysfunction. 9. For position changes, transfers and
9. Instructed in use of siderails, ambulation.
overhead trapeze, rollerpads, walker, 10. To maintain position of function
crane. and reduce risk of pressure ulcers.
10. Supported affected body parts or
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joints using pillows, rolls, foot
supports or shoes, gel pads, foam,
etc.

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Nursing Diagnosis: Acute Pain

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE: SHORT-TERM OBJECTIVES: 1. Noted client’s age and developmental 1. Affecting ability to report pain SHORT-TERM OBJECTIVES:
level and current condition. parameters.
 Facial grimace when After 8 hours of nursing After 8 hours of nursing
2. Determined and documented 2. To better understand the disease
trying to move intervention, the patient intervention, the patient
presence of possible process and apply proper
would be able to report that reported that pain is
pathophysiological causes of pain intervention
pain is relieved or relieved from 10/10 to
(inflammation; tissue trauma; 3. To help determine possibility of
controlled; follow prescribed 7/10.
fracture; surgery). underlying condition or organ
pharmacological regimen,
3. Assessed for referred pain. dysfunction requiring treatment.
SUBJECTIVE: and verbalize
4. Monitored skin color and 4. Are usually altered in acute pain.
nonpharmacological LONG-TERM OBJECTIVES:
 “Sakit akong likod og dili temperature and vital signs. 5. To promote nonpharmocological
methods that provide relief.
ko kalihok sa akong 5. Provided comfort measures, quiet pain management.
After 4 days of nursing
kamot og kini environment, and calm activities. 6. To distract attention and reduce
intervention, the patient
(percutaneous 6. Encouraged use of relaxation tension.
reported alleviation of pain
suprapubic catheter)” as LONG-TERM OBJECTIVES: techniques. Such as focused breathing 7. As timely intervention is more
with a pain scale of 4/10;
verbalized by the After 4 days of nursing and imaging. likely to be successful in alleviating
patient was able to
patient. 7. Worked with client to prevent pain. pain.
intervention, the patient demonstrate use of
 Patient had complaints would be able to
Used flow sheet to document pain. 8. To maintain “acceptable” level of
relaxation skills and
of dull pain at lower demonstrate Instructed client to report pain as pain and to alleviate pain.
use of diversional activities, as
back, intensified by relaxation soon as it begins.
skills and indicated, for individual’s
coughing, with a pain diversional activities, as 8. Encouraged pt to take medications
situation; verbalized sense
scale of 10/10. administered, as directed.
indicated, for individual’s of control of response to
situation; verbalize sense of acute situation and positive
control of response to acute outlook for the future.
situation and positive
outlook for the future.

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