Theory-based (Betty Neuman)

NURSING CARE PLAN

Name of Student: Jannel Reggie M.Pasa

Client’s Initials: M.S Stressor Classification: (Please check)
Age:68 Gender: Female Civil Status:Married Religion: Catholic ___/ Physiological (body structure and functions)
Allergies: None ______ Psychological (mental processes and emotion)
Diet: Diet as tolerated (DAT) ______ Socio-cultural (relationships, social expectations)
Date of Admission: May 3, 2023 ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression: Osteoporosis ______ Developmental (developmental processes over the lifespan)
NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME
Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
(Goal attainable within the shift) (with Rationale & Source)
Subjective: Acute pain r/t osteoporotic Short-term goal: PRIMARY INTERVENTIONS (focuses on
“ Sakit ako buko buko then thoracic kyphosis as evidenced by After eight hours of thorough strengthening the flexible line of defense through
nalain pod ako postura” as reports of sharp and knife-like nursing interventions, the preventing stress and reducing risk factors)
verbalized by the patient. patient will be able to; Promotive:
pain in the upper back lasting
➔ Make use of comfort I: Assess and manage pain
more than 3 weeks with a pain and ease measure R: Pain control is essential for the patient to
score of 6/10, loss of height, and techniques in relieving participate in rehabilitation.
spine malformations such as pain. S: Carpenito, L. J. (2016). Handbook of nursing
hunched- like posture secondary diagnosis (15th ed.). Lippincott Williams and
to osteoporosis. Wilkins.
Objective: Theoretical basis:
➔ Vital signs: Bone regeneration normally takes
HR: 58 bpm place much faster than the
RR: 16 cpm deterioration process and the
BP:130/80 mmHg bones grow in mass reaching a
➔ Facial Grimacing peak in a person’s 20s. As people
➔ Hump-like age, the breaking down process
appearance in the becomes faster than the
upper back. regeneration process. The
➔ Bone density: T-score amount of bone mass at the peak
of –2.7. can partly determine the likelihood
➔ Blood Chemistry of developing osteoporosis. There
result: are many risk factors. It is most
> Calcium 6.5 mg/dL common in older women, due to a
> Vitamin D15 nmol/L decrease in estrogen, as well as
people taking corticosteroids or
with a decreased dietary intake of
calcium and vitamin D.
➔ Perform range of
motion exercises
(ROM).
➔ Report satisfactory pain
control at a level of less
than 6 on a scale of 0
to 10.
Long-term goal:
After three days of nursing
interventions, the patient will be
able to;
➔ Exhibit increased
comfort such as
baseline levels for HR,
BP, respiration, and
relaxed muscle tone or
body posture
➔ Engage in desired
activities without an
increase in pain level
➔ Stop smoking, limit
alcohol intake to
maximum of 2 units per
day, and to improve
I: Encourage physical mobility and demonstrate
range of motion exercises.
R: To prevent muscle atrophy and joint
contractures.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.
Preventive:
I: Assist with repositioning
R: Pain and injury make positioning difficult for
some patients. Assist in repositioning every 2
hours as needed to prevent skin breakdown and
assist with mobility
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.
I: Assist with ROM activities
R: Immobility can cause atrophy of muscles.
Assist as necessary with ROM activities to prevent
injury.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.
 exercise and physical SECONDARY INTERVENTIONS (focuses on
activity. strengthening the internal lines of resistance and
➔ Have a healthy diet as protecting the basic structure through appropriate
well as to increase treatment of symptoms)
intake of calcium and Curative:
vitamin D supplements. I: Provide the patient alternative methods on
➔ Perform alternative relieving pain such as guided imagery, deep
methods on relieving breathing, music therapy, directed meditation,
pain. massage, hot and cold compress application to
➔ Verbalized a pain score the site of pain
of 0/10. R: Non-pharmacological interventions decrease
. fear, distress and anxiety, and to reduce pain and
provide patients with a sense of control.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.

I: Advise the patient to stop smoking, limit alcohol

intake to maximum of 2 units per day, and to
improve exercise and physical activity.
R: To prevent bone loss and to improve the
absorption of calcium in the bones.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.
I: Educate the patient on the relationship between
osteoporosis and calcium and vitamin D levels, as
well as the target dietary amounts for calcium and
vitamin D.
R: Vitamin D decreases bone loss and lowers the
risk of fracture, especially in older men and
women. Along with calcium, vitamin D also helps
to prevent and treat osteoporosis. To absorb
calcium efficiently, an adequate amount of vitamin
D must be present.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.

I: Refer the patient to the dietitian.

R: To provide specialized care and individualized
dietary programs geared towards improving bone
health.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.
 TERTIARY INTERVENTIONS (focuses on
maintaining wellness or protecting the client
system reconstitution through supporting existing
strengths and continuing to preserve energy)
Rehabilitative:
I: Provide a safe and hazard-free environment,
and assist the client to identify hazards in the
home environment
R: To maintain a conducive environment for
recovery and rehabilitation.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins.

I: Consult physical and occupational therapy as

appropriate
R: Consult with PT/OT for evaluation and rehab to
maintain functionality and mobility.
S: Carpenito, L. J. (2016). Handbook of nursing
diagnosis (15th ed.). Lippincott Williams and
Wilkins

References:
1. Carpenito, L. J. (2016). Handbook of nursing diagnosis (15th ed.). Lippincott Williams and Wilkins.
2. Marcus, R., Dempster, D. W., Cauley, J. A., & Feldman, D. (Eds.). (2013). Osteoporosis. Academic press.
3. Rachner, T. D., Khosla, S., & Hofbauer, L. C. (2011). Osteoporosis: now and the future. The Lancet, 377(9773), 1276-1287.
 Nursing Care Plan Product Assessment Rubric

CRITERIA Competent Advance Beginner Novice

All subjective and/or objective cues identified are The subjective and/or objective cues identified include some The subjective and/or objective cues identified include
Assessment aligned, relevant and sufficient in the formulation of data that are misaligned, irrelevant but sufficient enough in several data that are misaligned, irrelevant making it
(3) the nursing diagnosis formulating the nursing diagnosis insufficient in the formulation of the nursing diagnosis
(3) (2) (1)
The nursing diagnosis is appropriate based on the cues The nursing diagnosis is appropriate based on the cues The nursing diagnosis is inappropriate based on the cues
and the priority complaints of the patient or of the presented but may not necessarily be the priority nursing presented and does not reflect the patient’s response to
Diagnosis (3) case scenario problem based on the patient’s health situation or of the the illness.
(3) case scenario (1)
(2)
All the concepts, models and theories (at least 3) are The concepts, models and theories include some The concepts, models and theories are irrelevant and do
Theoretical relevant and substantially supports the nursing information that are irrelevant to the patient’s case, not substantially support the nursing diagnosis in relation
Basis (2) diagnosis in relation to the patient’s case however, the data (less than 3) still adequately supports the to the patient’s case
(2) nursing diagnosis in relation to the patient’s case (1.5) (1)
Goal/s set is/are specific, measurable, attainable, Goal/s set missed 1-2 elements but the statements are Goal/s set missed 3 or more elements and the statements
Goals/Goal realistic and time-bounded. Includes both short-term aligned to the identified nursing problem. Goal setting are not aligned to the identified nursing problem.
Setting and long-term goals and are aligned to the identified considers both short term and long-term care. (2)
(4) nursing problem. (3)
(4)
All interventions are related and responsive to the Interventions include some data that are unrelated and Interventions include several data that are unrelated and
Interventions identified needs and sufficient to help attain the goal. unresponsive to the identified needs, however, the identified unresponsive to the identified needs which results in the
(5) (5) interventions are sufficient to help attain the goal. non-attainment of the set goal/s.
(4) (3)
The subjective/objective data are aligned, relevant and The subjective/objective data include information that is The subjective/objective data include information that are
Evaluation adequate to assess the attainment of the outcome misaligned, irrelevant but adequate enough to assess the misaligned, irrelevant and are inadequate to assess the
(2) criteria. attainment of the outcome criteria. attainment of the outcome criteria.
(2) (1.5) (1)
At least 3 updated (within 8 – 10 years), accurate and Less than 3 updated (within 8 – 10 years), accurate and References provided are not updated, inaccurate,
References
credible references are provided using APA Format credible references are provided using APA Format (0.5) unreliable or no references provided
(1)
(1) (0)
Total Score
________________________________________
Name and Signature of the Faculty