St.

Anthony’s College
San Jose, Antique
Nursing Department

Name: A.M.M.N. Operation Performed: Open Reduction Internal Fixation ® Femur

Age/Sex: 9years old/Female Perioperative Phase: Post-operative Phase

NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE: Activity Introduction of Within 2 to 3 hours of Independent: After 3 hour of appropriate

“Gaparangluya lawas ko” intolerance r/t spinal anesthesia into appropriate nursing  Promote comfort  To enhance ability nursing intervention, the
as verbalized by the generalized the subarachnoid intervention the measures and to participate in patient’s demonstrate
patient weakness space at the lumbar patient will be able to provide for relief of activities. increase activity intolerance
area usually L4 and demonstrate increase pain.
L5 which causes activity tolerance.  Plan care with rest  To reduce or prevent
anesthetic effect or periods between fatigue.
the absence of activities
sensation in the
lower extremities  Assist in self care  To increase mobility
and lower abdomen activities, before and to protect or
resulting traumatic ambulation prevent patient from
OBJECTIVE: or pathophysiologic injury.
 grimace damage to their
 pale and weak in tissue causing body
appearance weakness  Perform ROM
 mostly confined on exercise (active  Inability rapidly
bed assistive). contributes to
 restless muscle shortening
 limited movements and changes in
 inability to perform periarticular and
ADL cartilaginous joint
structure which
contribute to the
limitation of motion.
  Emphasize  Promotes well being
adequate intake of and maximizes
fluids at least 1500- energy production.
2000 ml and
nutritious foods
such as fruits and
vegetables

 Observe and  Activity intolerance

document skin may lead to pressure
integrity at least 3 ulcer.
times within the
shift.

Name of Student: Cen Janber Cabrillos BSN-4 Clinical Instructor: Jerry V. Able, RN, MAN