FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Nursing Program

PRIORITIZATION OF PROBLEMS

Rank Problem Identified

1 Impaired physical mobility related to cognitive impairment
secondary to subacute sclerosing panencephalitis as evidenced by
limited range of motion
2 Disturbed (Altered) thought process related to changes in the
level of consciousness as evidenced by cognitive deficits
3 Self-care deficit related to the inability to perform activities of daily
living as evidenced by impaired motor functions
 NURSING CARE PLAN #1
By A.T., Cuenca, FSUU, SN

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data: Impaired Within 8 hours of nursing INDEPENDENT After 8 hours of nursing
No statements were physical intervention, the patient will 1. Check for functional level of - Understanding the particular level, intervention, the patient
verbalized by the mobility be able to: mobility. guides the design of best possible was able to:
patient. related to management plan.
cognitive • Maintain position of 2. Assess for impediments to - Identifying barriers to mobility (e.g., • Maintain position of
Objective data: impairment function and skin mobility. chronic arthritis versus stroke versus function and skin
• Inability to secondary to integrity as evidenced pain) guides design of an optimal integrity as evidenced
perform activities subacute by absence of treatment plan. by absence of
of daily living sclerosing contractures, footdrop, 3. Assess the strength to perform - This assessment provides data on contractures, footdrop,
independently panencephalitis decubitus, etc. ROM to all joints. extent of any physical problems and decubitus, etc.
• Loss of motor as evidenced • Demonstrate guides therapy. Testing by a physical • Demonstrate
function by paralysis techniques and therapist may be needed. techniques and
• Limited range of and limited behaviors that enable 4. Assess input and output record - Pressure ulcers build up more behaviors that enable
motion range of motion safe repositioning and and nutritional pattern and monitor rapidly in patients with a nutritional safe repositioning and
• Cognitive safety measures to nutritional needs as they relate to insufficiency. Good nutrition also safety measures to
impairment minimize potential for immobility. gives required energy for minimize potential for
• Past health injury participating in an exercise or injury
history of rehabilitative activities.
measles at 11 5. Evaluate the need for assistive - Correct utilization of wheelchairs, Goal met.
months of age devices. canes, transfer bars, and other November 11, 2021
assistance can enhance activity and 9:45 AM
No vital signs data lessen the danger of falls.
were recorded 6. Assist patient for muscle - Adds to gaining enhanced sense of
exercises as able or when allowed balance and strengthens
out of bed; execute abdominal- compensatory body parts.
tightening exercises and knee A.T., Cuenca, FSUU, SN
bends; hop on foot; stand on toes.
7. Present a safe environment: bed - These measures promote a safe,
rails up, bed in a down position, secure environment and may reduce
important items close by. risk for falls.
8. Show the use of mobility devices, - These devices can compensate for
such as the following: trapeze, impaired function and enhance level
crutches, or walkers. of activity. The goals of using such
aids are to promote safety, enhance
mobility, avoid falls, and conserve
energy.
9. Keep limbs in functional - This avoids footdrop and too much
alignment with one or more of the plantar flexion or tightness. Maintain
following: pillows, sandbags, feet in dorsiflexed position.
wedges, or prefabricated splints.
10. Set goals with patient or - This enhances sense of anticipation
Significant Other for cooperation in of progress or improvement and
activities or exercise and position gives some sense of control or
changes. independence.
 NURSING CARE PLAN #2
By A.T., Cuenca, FSUU, SN

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data: Disturbed Within 8 hours of nursing INDEPENDENT After 8 hours of nursing
No statements were (Altered) intervention, the patient will 1. Identify factors present - Identifying factors present is intervention, the patient
verbalized by the thought be able to: [acute/chronic brain syndrome important to know the was able to:
patient. process (recent stroke, Alzheimer’s causative/contributing factors.
related to • Maintain reality disease), brain injury or increased • Maintain reality
Objective data: changes in the orientation and intracranial pressure, anoxic event, orientation and
• Inability to level of communicate clearly acute infections, malnutrition, sleep communicate clearly
perform activities consciousness with others or sensory deprivation, chronic with others
of daily living as evidenced • Interacts and mental illness (schizophrenia)]. • Interacts and
independently by cognitive cooperates with staff in 2. Review laboratory values for - Monitoring laboratory values aids in cooperates with staff in
• Loss of motor deficits the hospital setting abnormalities such as metabolic identifying contributing factors. the hospital setting
function alkalosis, hypokalemia, anemia,
• Limited range of elevated ammonia levels, and signs Goal met.
motion of infection. November 11, 2021
• Cognitive 3. Interview SO or caregiver to - This is to provide baseline for 11:20 AM
impairment determine patient’s usual thinking comparison.
• Past health ability, changes in behavior, length
history of of time problem has existed, and
measles at 11 other pertinent information.
months of age 4. Perform periodic - Early recognition of changes A.T., Cuenca, FSUU, SN
neurological/behavioral promotes proactive modifications to
No vital signs data assessments, as indicated, and plan of care.
were recorded compare with baseline. - Cognition/thinking often improves
5. Assist with treatment for with treatment/correction of
underlying problems, such as medical/psychiatric problems.
anorexia, brain injury/increased
intracranial pressure, sleep
disorders, biochemical imbalances.
6. Provide safety measures (e.g., - It is always necessary to consider
side rails, padding, as necessary; the safety of the patient.
close supervision, seizure
precautions), as indicated.
7. Maintain a pleasant and quiet
environment and approach patient
in a slow and calm manner.
8. Reduce provocative stimuli,
negative criticism, arguments, and
confrontations.
9. Schedule structured activity and
rest periods.
10. Provide nutritionally well-
balanced diet, incorporating
patient’s preferences as able.
Encourage patient to eat. Provide
pleasant environment and allow
sufficient time to eat.
- Patient may respond with anxious
or aggressive behaviors if startled or
overstimulated.
- This is to avoid triggering fight/flight
responses.
- This provides stimulation while
reducing fatigue.
- These enhance intake and general
well-being.