Nursing Care Plan

Clients Name: Manuel Santos Date: 28/04/21 Clinical Area of Assignment:

Cues/Evidences Nursing Diagnosis Outcome Criteria Nursing Interventions Rationale Evaluation

Subjective:
 Patient describes his lower back
 Impaired physical  Patient will verbalize  Assist the patient to  Stretching can help the patient 
pain to be a “stabbing, deep,
mobility related to less fear of falling and perform stretches for at to regained energy.
and dull pain” that spreads to
his legs. pain as evidence reduced pain with any least 10 minutes every
 Patient is unable to sleep due to by limping, physical activity or morning to minimize the
the pain worsening at night.
slumped movement and express pain.
 Difficulty in walking
 He feels tired in the morning shoulders, feelings of increased  Encourage the patient to  Walking with crutches will

and is unable to work especially inability to strength and ability to walk regularly with serve as physical therapy and
with his clients due to the pain
successfully move. crutches. will gradually reduce pain and
worsening
 Rates pain 7 in a scale of 0-10. complete the range  Patient shows ability to restore ambulation.

 Appears anxious and of motion tests for maintain balanced and  Assess the understanding  The risk for effects of
immobility such as muscle
uncomfortable; frowns and
the legs. comfortable ambulation. of the patient or caregiver weakness, skin breakdown,
grimaces. inflammation of the lungs,
 Patient practices safety about immobility and its constipation, blood clot in the
Objective:
veins of a patient’s leg, and
 Underwent prostatectomy
followed by cycles of radiation
and chemotherapy a year prior
 Patient returns to
to present health concern due
to prostate cancer.
 Present health concern started
8 to 10 months ago.
 Patient will regain the 
 Range of motion test of legs:
1. Standing
- Only able to lift knees up to
20 degrees from straight
position when marching in
place.
2. Sitting
- Only able to lift each leg
with knee unbent up to 15
degrees before paint starts.
3. Lying Prone
- Only able to lift each leg 10
degrees before pain begins.
health measures to implications. depression are also to be
considered in patients with
reduce the risk of injury. temporary immobility.
 Present a safe environment:
 These measures promote a safe,
participating in daily bed rails up, bed in a down
secure environment and may
and desired activities position, important items
reduce risk for falls while
close by.
impaired.
Execute passive or active
 Exercise enhances increased
ability sustain or assistive ROM exercises to
venous return, prevents
increase strength and all extremities.
stiffness, and maintains muscle
function with the
strength and stamina. It also
affected body parts.
avoids contracture deformation,
which can build up quickly and
could hinder prosthesis usage.
 Establish measures to
 This is to prevent skin
prevent skin breakdown
breakdown, and the
and thrombophlebitis from
compression devices promote
prolonged immobility:
 Vital Signs 1. Clean, dry, and moisturize increased venous return to
1. Heart Rate: 110 BPM
skin as necessary. prevent venous stasis and
2. Respiratory Rate: 22 CPM
2. Use anti embolic stockings possible thrombophlebitis in the
3. Blood Pressure: 130/80 mmHg
or sequential compression legs.
 Repositions every 2-3 minutes
devices if appropriate.
while sitting.
3. Use pressure-relieving
 Slumps shoulders when sitting
 Limping is observed when devices as indicated (gel
entering the examination room.
mattress).

 Let the patient accomplish

tasks at his or her own  Healthcare providers and

pace. Do not hurry the significant others are often in a

patient. Encourage hurry and do more for patients

independent activity as able than needed. Thereby slowing

and safe. the patient’s recovery and

reducing his or her confidence.