NURSING CARE PLAN ASSESSMENT Subjective: Hindi siya makatagilid sumasakit daw ung bali niya sa may bewang

kapag gumagalaw as verbalized by the son of the patient. bjective: !mpaired ability to turn side to side !mpaired ability to move from supine to sitting vise versa. "#$ presence of pelvic fracture "#$ %eneral weakness &remors noted on left arm and hands "#$ %eneral body weakness b. NURSING DIAGNOSIS ' !mpaired physical mobility related to pain secondary to musculoskeletal impairment as evidenced by body weakness PLANNING (fter ) hours of nursing intervention the patient will: a. *erbalize understanding of the situation +risk factors, individual therapeutic regimen and safety measures. -emonstrate techni.ues+ behaviors that will enable safe repositioning /aintain position of function and skin integrity of the patient as evidenced by absence of contractures, foot drop, decubitus, etc. INTERVENTION determine diagnoses that contribute to immobility "e.g. fractures, hemi+para+tetra+.uadrip egia$ 0ote individual risk factors and current situation, such pain, age, general weakness, debilitation -etermine perceptual+ cognitive impairment to follow directions -etermine functional level classification 0ote presence of complications related to immobility bserve skin for reddened areas+shearing. 1rovide appropriate pressure to relief 1rovide regular skin care if appropriate (ssist with activities of hygiene, toileting, feeding, as indicated. !nvolve client S+ in determining activity schedule RATIONALE &o identify causative+ contributing factors. EVALUATION (fter ) hours of nursing intervention the patient was a. *erbalized understanding of the situation +risk factors, individual therapeutic regimen and safety measures. -emonstrated techni.ues+ behaviors that will enable safe repositioning /aintained position of function and skin integrity of the patient as evidenced by absence of contractures, foot drop, decubitus, etc.

b.

c.

c. &o assess patients functional ability

&o reduce friction, maintain safe skin+tissue pressures and wick away moisture &o prevent complications &o promote optimal level of functioning

&o promote commitment to plan, ma2imizing outcomes.

ASSESSMENT Subjective: Hindi na makagalaw si nanay simula nung na3 stroke siya as verbalize by the son of the patient bective: "#$ %eneral

NURSING DIAGNOSIS ' !mpaired physical mobility related to 0euromuscular impairment

INFERENCE Hypertension cclusion within vessels of the brain parenchyma 4 -isruption of blood supply in the brain area 4 &issue and cell necrosis

PLANNING (fter the rotation and nursing intervention the patient will: a. /aintain position and function and skin integrity as evidenced by absence of contractures,

INTERVENTION -etermine diagnosis that contributes to immobility "e.g. fractures, hemi+ para+ tetra+ .uadriplegia$ (ssess nutritional status and S+ others report of energy level. -etermine degree

RATIONALE &o identify causative+ contributing factors.

EVALUATION (fter the rotation and nursing intervention the patient will: c. /aintain position and function and skin integrity as evidenced by absence of contractures, foot drop,

body weakness &remors noted on left arm and hands !nability to perform gross+fine motor skills "#$ 1aralysis of left side of the body functional level scale: 5 "does not participate in activity$

4 -estruction of 0euromuscular junctions 4 !nterruption in transportation of electrical impulses to the neuromuscular receptors 4 /6(7%!(+89(-: ! : H;/!17;%!(

b.

foot drop, decubitus and so forth. S+ will demonstrate techni.ues+ behaviors that will enable safe repositioning

of immobility in relation to functional level scale (ssist or have significant other reposition client on a regular schedule "turn to side every < hours$ as ordered by the physician 1rovides safety measures "side rails up, using pillows to support body part$ ;ncourage patient=s S+ =s involvement in decision making as much as possible !nvolve S+ in care, assisting them to learns ways of managing problems of immobility.

&o assess functional ability

d.

&o prevent complication

decubitus and so forth. S+ will demonstrate techni.ues+ behaviors that will enable safe repositioning

&o provide safety

;nhances commitment to plan optimizing outcomes &o impart health teaching.

ASSESSMENT Subjective: Simula nung na i3 stroke si nanay, na bedridden na siya bjective: "#$ 0%& insertion 1atient is unable to: >H6%!;0;? (ccess and prepare bath supplies @ash body Aontrol washing mediums >-:;SS!0% (0%: /!0%? btain articles for clothing 1ut on clothes /aintain appearance at an acceptable level >B;;-!0%? 1repare+obtain food for ingestion Handle utensils Cring food to mouth Ahew and swallow up food

NURSING DIAGNOSIS Self care deficit : hygiene, dressing and grooming, feeding and toileting related to 0euromuscular impairment

INFERENCE Hypertension cclusion within vessels of the brain parenchyma 4 -isruption of blood supply in the brain area 4 &issue and cell necrosis 4 -estruction of 0euromuscular junctions 4 !nterruption in transportation of electrical impulses to the neuromuscular receptors 4 /6(7%!(+89(:! : H;/!17;%!(

PLANNING (fter the rotation and nursing interventions. &he patient should: a. meet all therapeutic self care demands in a complete absence of self care agency b. (CS;0A; B SDS B 09&:!&! 0(7 -;B!A!&. >Adequate nutritional intake] c. % - SE!0 &9:% :, 0 :/(7 9:!0; 9&19&, (CS;0A; B ;-;/(, H61;: (0H61 * 7;/!( >Fluid and Electrolyte balance] d. (CS;0A; B -;A9C!&9S 97A;:S (0B 97 - :S !0 C;&@;;0 7!0;0S+A7 &H!0 % (0- SE!0 >Clean, Intact skin and mucus membrane] e. (CS;0A; B (C- /!0(7

INTERVENTION 1rovide enteric nutrition *!( 0% &ube feeding. High fowlers for at least FG minutes after feeding. Aareful !+ /onitoring and apply necessary dietary restrictions Ahange position at least 0A; every two hours or more often when needed. 1rovide padding for the elbows, needs, ankles and other areas for possible skin abrasion. (n adult diaper should be @ :0 at all times. Ahange the diaper as soon as patient defecated.

RATIONALE &o meet patient=s need for an ade.uate nutritional intake. &o establish careful assessment on patients fluid and electrolyte balance. &o prevent decubitus ulcerations.

EVALUATION (fter the rotation and nursing interventions. &he patient should: f. meet all therapeutic self care demands in a complete absence of self care agency g. (CS;0A; B SDS B 09&:!&! 0(7 -;B!A!&. >Adequate nutritional intake] h. % - SE!0 &9:% :, 0 :/(7 9:!0; 9&19&, (CS;0A; B ;-;/(, H61;: (0H61 * 7;/! ( >Fluid and Electrolyte balance] i. (CS;0A; B -;A9C!&9S 97A;:S (0B 97 - :S !0 C;&@;;0

&o protect the patient=s skin integrity maintaining his first line of defense against sickness and infection. &o prevent soiling of bed sheets, clothes and linens providing ma2imum

 1ick up food >& !7;&!0%? %o to the toilet

(0- C7(--;: -!S&;0&! 0, :;A&(7 B9770;SS (01:;SS9:;, 1(!0 !0 -;B;A(&! 0 > Meeting toileting demands ?

1romote an ;nvironment conducive to rest and recovery. -ecrease stimuli and /etabolic demand of the body. 1assive : / ;2ercises ;arly morning once a day, FH times targeting both upper and lower e2tremities. ' 7astly, -o health teaching when S+ is at the optimum level to receive information.

comfort and prevention of skin irritation if feces remain in contact with the patient=s skin for a long time. &o conserve energy promoting rest and recovery.

j.

&his is to improve circulation, reducing the risk of atheromatous formation.

7!0;0S+A7 & H!0% (0SE!0 >Clean, Intact skin and mucus membrane] (CS;0A; B (C- /!0(7 (0C7(--;: -!S&;0&! 0, :;A&(7 B9770;SS (01:;SS9:;, 1(!0 !0 -;B;A(&! 0 > Meeting toileting demands ?

FH. &o educate the S+ what factors have contributed to the client=s illness and educating them to decrease, if not totally eliminate those contributory factors to prevent recurrence of the disease and promote change for a healthy lifestyle.