8.1nursing-care-plan.docx

Nursing Care Plan Cues

Actual/Potential Nursing Diagnosis

Expected Outcome (SMART)

Nursing Orders (OME)

S – “Di ko kaubra sakong mga hilimuon kay di ko makagiho gid kay sakit samot akong likod og mugiho ko” as verbalized by the patient.

Activity intolerance related to decreased energy requirements as evidenced by decreased muscle strength.

After 2 days of nursing intervention, the patient will be able to maintain activity level with in capabilities as evidenced by normal vital signs during activity, as well as absence of weakness, pain, and difficulty accomplishing tasks.

-monitor vital signs and recorded.

O–  

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Weak in appearance Cannot perform ADL’s alone With limited ROM Muscle strength weakness Braiden scale: 13

Rationale

-to help determine patients current health status and evaluate effectiveness of nursing intervention rendered. -monitor intake and -to evaluate proper output as order. functioning of her kidney in relation to her present condition. -assess ability to -to determine the perform ADL. capacity of patient in performing ADL. -assess physical mobility -to know if there’s any status. changes on patient’s condition specifically on physical aspect. -assist patient to do -to maximize full active ROM exercise strength. like flexing of both extremities. -promote rest and -to conserve energy. comfort. -emphasize importance -to promote of frequent ambulation. circulation. -encourage to verbalize -to determine other feelings and concern factors that might regarding her present contribute to patient’s condition. present condition.

Evaluation

After 2 days of intervention the patient is still can’t perform activity by self and need assistance in doing activity.

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-emphasize importance of compliance to treatment and medication.

Reference:www.pdfcoke.com and nurseslabs.com

-to achieve therapeutic effect of medication and for fast recovery.

Nursing Care Plan

Cues

Actual/Potential Nursing Diagnosis

Expected Outcome (SMART)

Nursing Orders (OME)

Rationale

Evaluation

“gasakit gid yah ang akon nga likod, kung mag giho lang ko gamay kay sakit sakit na dayun” as verbalized by the patient.

Acute pain related to fracture as evidenced by pain scale of 7/10.

After 2 days of nursing intervention the patient will be able to relieve the pain and move her back constantly.

-perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. -assess vital signs, noting tachycardia, hypertension, and increase respiration, even if client denies pain. -reduce or eliminate factors that precipitate or increase pain experience. -elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning abdominal breathing, music therapy, or peaceful imaging. -create a quiet, no disruptive environment

-pain is a subjective experience and must be described by the client in order to plan effective treatment.

After 2 days of nursing intervention, the patient verbalized pain scale 5/10.

-facial grimace -pain scale : 7/10 With limitations in movements.

-changes in the V/S often indicate acute pain and discomfort.

-personal factors can influence pain and pain intolerance. -relaxation techniques help reduce skeletal muscle tension, which will reduce the intensity of pain.

-comfort and quite atmosphere promote a

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with dim lights and comfortable temperature when possible.

relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction.

-instruct client to report any improvement/ exacerbation of pain.

-unrelieved pain can create other problems such as anger, anxiety, immobility, respiratory problems and delay in healing. -only client can judge the level and distress of pain, pain management should be a team approach that includes the client. -to promote circulation to prevent excessive tissue pressure.

-encourage verbalization about feelings of pain.

-encourage mobilization of back and extremities.

Reference:www.pdfcoke.com and nurseslabs.com