FAR EASTERN UNIVERSITY

Institute of Nursing

NURSING CARE PLAN

BSN215/GROUP 59 2011
NURSING DIAGNOSIS ANALYSIS GOALS & OBJECTIVES INTERVENTION RATIONALE

January 10,
EVALUATION

Impaired physical mobility related to neuromuscul ar impairment Subjective: Hindi maigalaw ni tatay yong right side ng body nya as verbalized by the daughter of the patient. Objective: Vital signs BP:140/80 Temp.: 36 C

Mobility and activity tolerance are affected by and disorder that impairs the ability of the nervous system, musculoskeletal, cardiovascular, respiratory and vestibular apparatus. (p.1117:Fundamental
s of Nursing, Vol II of Kozier)

Goal: After the nursing intervention the patient will prevent injury. Objectives: After 8 hours of nursing intervention

After the nursing intervention the patient has prevented injury by observing safety measures. After 8 hours of nursing intervention

People of any age can fall, but infants and elders are particularly prone to falling and causing serious injury. Falls are the leading cause of injuries among

The patient will maintain skin integrity as evidenced by absence of pressure ulcer.

Document skin status at least each shift Assess nutritional status and decreased subcutaneous fat and thinning of the skin.

Baseline data (p.917:Fundamentals of

Nursing, Vol II of Kozier)

Elders at risk for skin breakdown. (p.1140:Fundamentals

of Nursing, Vol II of Kozier)

The patient has maintained skin integrity as evidenced by absence of pressure ulcer.

Remove moisture from the skin Apply protective barrier such as creams or pads

Prevention of pressure ulcer (p.917:Fundamentals of

Nursing, Vol II of Kozier)

To absorb excess moisture. (p.917:Fundamentals of

Nursing, Vol II of Kozier)

PR: 60bpm RR: 20cpm. Paralysis on right side of the body Body weakness

older adults. (p.719:Fundamentals

of Nursing, Vol I of Kozier)

Ensure the bed is clean and dry.

Frequent change of position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures. Position changes also maintain muscle tone and stimulate postural reflexes. (p.1140:Fundame
ntals of Nursing, Vol II of Kozier)

Wrinkled or damp sheets increase the risk of pressure ulcer formation. (p.1130:Fundamentals
of Nursing, Vol II of Kozier)

Reposition the patient every 2 hours (turn side to side).

Significant others will demonstrate safety practices.

To help reduce pressure on bony prominence and avoid tissue trauma. (p.1140:Fundamentals
of Nursing, Vol II of Kozier)

Keep side rails up Keep bed in the low position. Remove unsafe objects in bed.

To promote safety (p.719:Fundamentals of

Nursing, Vol I of Kozier)

Significant others have demonstrated safety practices.

To promote safety (p.719:Fundamentals of

Nursing, Vol I of Kozier)

To promote safety (p.719:Fundamentals of

Nursing, Vol I of Kozier)