Patient's Problem List

Problems were prioritized according to date it was identified. Problems identified in the
same date were prioritized according to Abraham Maslow's hierarchy of needs. Physiological
problems are prioritized according to the following scheme: airway, breathing, circulation and
pain.

NCP Nursing Diagnosis Date Identified Date Evaluated

Number
1 Acute pain related to inflammation of the November 9, Short Term Goal:
right shoulder 2010 November 9, 2010

2 Impaired physical mobility in the right November 10, Short Term Goal:
shoulder related to musculoskeletal 2010 November 10, 2010
impairment
3 Selfcare deficit related to November 10, Short Term Goal:
2010 November 10, 2010
Nursing Care Plan Number 1

Date Identified: February 19, 2010

Subjective Cue: “ sakit ghapun akong bukton , mga 7 sa imong kasakiton sa imong giingon.”
Objective Cues:

• deep furrows at forehead

• guarding behavior at the right shoulder
• diaphoretic
• limited movement in the right shoulder
• facial grimace noted
• clenched fists

Nursing Diagnosis:
Acute pain related to inflammation of the right shoulder
Objectives:
Short Term Goal:
Within 4 hours of providing relevant health teachings and rendering effective nursing
interventions, the patient will be able to report pain is relieved/controlled from the pain scale
of 7 to 5 and below.
Nursing Implementation:
Interventions Rationale
Independent Interventions
1. Assess the general condition of the Provides baseline data
patient
2. Monitor patients skin color/ These are usually altered in acute pain.
temperature and vital signs
3. Assess pain characteristics: Evaluating what the pain means to the
Quality (e.g. sharp burning, pricking) patient will directly influence patient’s
Severity (scale 1-10, 10 most severe) response.
Location (anatomical description)
Onset (gradual or sudden)
Duration (how long,
intermittent/continuous)

4. Determine/document presence of Determine what kind of nursing

possible pathophysiological/psychological interventions to be done.
cause of pain
5. Note location over the different parts of This can influence as well as add up to the
the body for any skin abrassion pain experinced
 6. Provide calm, quiet environment. Limit Promotes non-pharmacological pain
patient's activity during distress. Have management.
patient resume activity gradually and
increase as individually tolerated.
7. Apply cold compress as ordered Cold compress may reduce local edema and
promote some numbing, thereby promoting
comfort.
8. Support the area with pain when Reduces pain and provides support to the
coughing or whenever pain is felt affected part.
9. Encourage patient to verbalize pain In the midst of painful experiences patient’s
whenever it is felt. perception of time may become distorted.
Prompt responses to complaints may result
in decreased anxiety in patient.
10. Encourage patient the use of relaxation Relieves pain or to divert the patients
techniques such as focused breathing attention.

11. Encourage patient to ambulate within Prevents anticipatory pain and any further
client’s tolerance complications associated with immobility
(e.g., decubitus ulcer, muscle weakness)

Evaluation:
Short Term Goal:
Goal Met. After 4 hours of providing relevant health teachings and rendering effective
nursing interventions, the patient was able to verbalize pain is relieved/controlled from pain
scale of 7 to 5, “ makaya2x namn ang sakit, mga 5 xa imong gi.ingon”
Date Evaluated: November 9, 2010

Nursing Care Plan Number 3

Date Identified: November 10, 2010
Subjective Cue: “ Wala pa lagi ko kaligo.”
Objective Cues:

• unchanged clothes
• minor foul odor noted
• untrimmed nails and toenails
• yellow cerumen
• Minimal dirt lodge under finger nails

Nursing Diagnosis
Self-care deficit: bathing/hygiene, dressing/grooming related to musculoskeletal
impairment
Objectives:
Short Term Goal:
Within 4 hours of providing relevant health teachings and rendering effective nursing
interventions, the patient will be able to perform hygienic measures such as changing the dress,
combing the hair and trimming his fingernails.

Nursing Implementation:
Interventions Rationale
Independent Interventions
1.Identfy degree of individual Assess the degree of disability
impairment/functional level
2. Provide privacy during personal care Patient’s may take longer to dress and
activities privacy is fundamental to most patient
3. Perform Cleansing Bed Bath Promotes sense of well-being and promote
hygiene
4. Instructed to change clothing especially Maintains appearance at a satisfactory level
after taking a bath and when sweating
5. Encourage patient to increase fluid Prevents excessive drying of the skin
intake
6. Encourage to perform oral care Eliminates halitosis
8. Stress the importance of proper hygiene Gives the patient and significant other the
real essence of performing personal hygiene
9 Instruct the SO to assist client in the care Patients may require podiatric care to
of fingernails and toe nails as required prevent injury to feet during nail trimming
10. Instruct the patient as well as Promotes general hygiene
significant other(s) to do self-care as often
as possible
11. Instruct the patient to make available These are materials used for rendering
 of the materials for grooming such as soap, hygiene to the patient.
shampoo, comb etc.
12. Teach family/significant other(s) to This demonstrates caring/concern, but does
foster independence and to intervene if not interfere with patient’s efforts to
the patient becomes fatigue, is unable to achieve independence
perform task or becomes excessively
Frustrated

Evaluation:
Short Term Goal:
Goal Met. After 3 hours of providing relevant health teachings and rendering effective nursing
interventions, the patient was able to achieve general body hygiene/bathing,
dressing/grooming as evidenced by changing the clothes he wears, tied the hair neatly and
brushed his teeth.
Date Evaluated: November 10, 2010

Nursing Care Plan Number 2

Date Identified: November 10, 2010
Subjective Cue: “ dili na ko masaka ug malihok akong abaga”
Objective Cues:

• Right shoulder cant be raised forward and sideward

• Facial grimace noted when he tried to move his right shoulder
• Deep furrows in the forehead was also observed
• For injection of corticosteroid (depo-medrol)
Nursing Diagnosis
Impaired physical mobility in the right shoulder r/t musculoskeletal impairement
Objectives:
Short Term Goal:
Within 4 hours of providing relevant health teachings and rendering effective nursing
interventions, the patient will be able to demonstrate techniques or behaviors that enable him
to move his right extremities.
Nursing Implementation:
Interventions Rationale
Independent Interventions
1.Assess the general condition of the Serves as baseline data and information
patient source
2. monitor clients vital signs To obtain baseline data
3. Apply cold compress to affected area To relax the muscles

4. Instruct to use siderails or roller pads To prevent accident and falls

5. Support affected body parts/ joints using To Maintain position of function
pilliows and rolls
6.Instruct to report any unsuallities noted To rule out worsening of underliying
at affected side condition/ development of complication
7. Instruct to do ROM as tolorated Encourage movement in the extreamities
and increase circulation
8. Provide client ample time to perform To promote independencem to be able
mobility related task such as ADL. finish task succesfully
9. Encourage adequate rest periods To prevent fatigue and to decrease
metabolism demands.
10. Encourage adequate intake of fluids To promote well being and maximize energy
and nutritious foods. production

Evaluation:
Short Term Goal:
 Goal Met. After 4 hours of providing relevant health teachings and rendering effective
nursing interventions, the patient was be able to perform ROM and some techniques that
would enable him to right extreamity.

Date Evaluated: February 9, 2010