Nursing Care Plan
Assessment Diagnosis Rationale Goal & Objectives Interventions Rationale Evaluation
Subjective: Impaired Limitation in After 2hrs of nursing Independent: Independent: After 2hrs of nursing
physical independent, intervention, the intervention, the
“Grabe mobility, related purposeful patient -Check for functional -Understanding the patient
makulogon. to pain as physical level of mobility. particular level, guides
Mahirap evidenced by movement of the -will verbalize the design of best - verbalized
maghiro” range of motion affected leg understanding of possible management understanding of
limitations, situation and plan. situation and
“Ngonian, limited muscle individual treatment individual treatment
paano pa kaini. strength or regimen and safety -Evaluate patient’s ability -Restricted movement regimen and safety
Dae ngani control, and measures to perform Activities of influences the capacity measures
makahiro” impaired -will verbalize Daily Living efficiently to perform most - verbalized
coordination. understanding and and safely on a daily activities of daily living. understanding and
As verbalized by demonstrate use of basis. Safety with ambulation demonstrated use of
the patient adaptive device(s) to is a significant matter. adaptive device(s) to
increase mobility. Determines strengths increase mobility.
Objective: or insufficiency and
-weakness may give information
-range of motion After 3 days of regarding recovery. After 3 days of
limitations nursing intervention, This helps out in nursing intervention,
-limited muscle the patient: preference of actions the patient:
strength or
control - will increase -Evaluate the need for -Evaluate the need for - displayed increased
Impaired strength and assistive devices. assistive devices. strength and
coordination endurance of left leg endurance of left leg
-postural -will not develop
instability complications of -Present a safe -These measures -did not develop
immobility environment: bed rails promote a safe, complications of
up, bed in a down secure environment immobility
position, important items and may reduce risk
close by. for falls
-Establish measures to -This is to prevent skin
prevent skin breakdown breakdown, and the
and thrombophlebitis compression devices
from prolonged promote increased
immobility: venous return to
prevent venous stasis
and possible
thrombophlebitis in the
legs
-Execute passive or
active assistive ROM -Execute passive or
exercises to all active assistive ROM
extremities. exercises to all
extremities.
-Execute passive or
active assistive ROM -These devices can
exercises to all compensate for
extremities. impaired function and
enhance level of
activity. The goals of
using such aids are to
promote safety,
enhance mobility,
avoid falls, and
conserve energy.
-Give positive
reinforcement during -Give positive
activity. reinforcement during
activity.
-Give positive
reinforcement during -Position changes
activity. optimize circulation to
all tissues and relieve
pressure
- encourage deep
breathing and relaxation - leads to a reduction
techniques in stress levels and
helps divert attention
from pain
-encourage participation
in self-care -enhances self-
concept and sense of
independence
-encourage adequate
intake of fluid -to increase blood flow
to muscles and bone
to improve muscle
tone, preserve joint
mobility; prevent
contractures or
atrophy and calcium
resorption from
disuse.
-Provide footboard, wrist
splints, trochanter or -Useful in maintaining
hand rolls as a functional position of
appropriate. extremities, hands,
and feet, and
preventing
complications
-Assist with self-care
activities (bathing, -Improves muscle
shaving). strength and
circulation, enhances
patient control in the
situation, and
promotes self-directed
wellness.
-Teach patient and
significant others in the -Effective pain
use of analgesics and intervention will
instruct non enhance the patient’s
pharmacological pain ability to engage in
management such as appropriate activity
imagery, relaxation, and and exercises.
distractions.
Dependent:
Administer medications Dependent
as appropriate To reduce pain that
impedes movement
Collaborative:
- Consult with physical Collaborative:
therapist, as indicated -to develop individual
exercise/mobility
program and identify
appropriate mobility
devices
