NURSING CARE PLAN

Problem 1: Risk for Impaired Skin Integrity related

to Prolonged Bed Rest.
Prioritization: Medium Priority.
03/22/2014

Date Performed:

Reason: Its a non life threatening problem that needs nursing intervention.
Goal: Patients skin remains intact
Cues

Desired Outcome

Short Term:
After 8 hours of
Pt demonstrated
nursing
discomfort
intervention
through grimacing Patient's skin
and the tightening remains intact, as
of her muscles
evidenced by no
during a BM clean redness over
up.
bony
prominences and
Objective:
capillary refill <6
seconds over
Pt is physically
areas of redness.
immobile and
unable to get out
Long Term:
of bed.
Patient will not
Subjective:

Pt is incontinent
of her bowels,
which leads to
moisture on her
skin.

develop any
further skin
breakdown.

Intervention

Rationale

Independent:
1. Educate family and
caregivers on the
importance of keeping
the skin clean and dry.

Moisture softens
the skin and
causes a break in
the skin integrity.

2. Reposition the
pt at least once
every two hours

Positioning
interventions
reduce pressure
and shearing
force to the skin

3. Keep the skin

clean and dry

4. Monitor skin
condition at least
once a day for
color or texture
changes,
dermatological
conditions, or
lesions

Moisture softens
the skin and
causes a break in
the skin integrity
Systematic
inspection can
identify
impending
problems early

NURSING CARE PLAN

Evaluation: Goal met. After 8 hours of nursing intervention patient's

skin remains intact, as evidenced by no redness over bony prominences and
capillary refill <6 seconds over areas of redness.

Problem 2: Impaired Verbal Communication related

to Brain Injury.

DatePerformed:03/22/2014

Level of Prioritization: Medium Priority

Reason: Its a non life-threatening problem but specifically related
to patients current illness.
Goal: Patient is able to communicate effectively
Cues
Difficulty
vocalizing
words
Inability
to speak
dominant
language
Inability
to recall
familiar
words,
phrases,
or names
of known
persons,
objects,
and
places

Desired
Outcome
Short
term:
After 3
hours of
nursing
intervention
s Patient
and care
providers
will
establish a
means of
communicat
ion as
measured
by patient
able to
respond to
yes/no
questions
by means of
nodding .
Long term:
Within 3

Intervention

RATIONALE

Assess the patients primary

and preferred means of
communication
(verbal,written,gestures)

For the care

provider to
determine the
best method for
the patient

Anticipate patient needs and

pay attention to non verbal

Provides
reassurance to
the patient

Listen attentively when the

patient attempts to
communicate. Clarify your
understanding of the patients
communication
Never talk in front of the
patient as though he or she
cannot hear or comprehend
Maintain eye contact with the
Patient when speaking

Decrease
frustration and
demonstrates
caring

Eye contact lets

the patient know
that they have
your attention
when trying to
Communicate

NURSING CARE PLAN

days of
rendering
nursing
intervention
Patient will
be able to
use a form
of
communicat
ion to get
needs met
and relate
to his
environmen
t.

COLLABORATIVE
Provide patient with an
appointment with a speech
therapist, if not already done.
See the patient is well-rested
before each session with
speech therapist

This allows the

patient to stay
focused and
reduces
frustration

Evaluation: Desired outcome partially met as evidenced by patient able to

respond to yes/no questions by means of nodding, patient oriented and nods
head in understanding of care.

Problem 3: Constipation related Prolonged Bed

Rest
Level of prioritization: Medium priority
03/22/2014

Date performed:

Reason: Its a non life threatening problem that may affect bowel movement
pattern of patient that will affect health problem but can be intervened.
Goal: Patient will have a normal elimination pattern.
Cues

Desired outcome

Intervention

RATIONALE

NURSING CARE PLAN

Subjective:

Short term:

Maglisod sya ug
libang kada
adlaw as
verbalized by the
relatives

After 1 hour of
nursing
intervention, family
or caregiver will
verbalize measures
that will prevent
recurrence of
constipation as
measured by
Passage of soft,
formed stool at
frequency
perceived as
normal by the
patient, defecate at
least once a day

Objective:
Hard formed stool
Defecation fewer
than 2x a week
Infrequent
passage of stools
Abdominal
distention
Restlessness

Long Term
After 3 days
of nursing
interventions, the
client will not
experience
constipation.

1.Asses usual
pattern of
elimination
(size, quality,
frequency)

2.Asses activity
level

3. Evaluate
usual dietary
habits, eating
habits, and
liquid intake
4. Provide
health teaching
to family and
caregivers the
importance of
the following:
A balanced diet
that contains
adequate
fiber( fresh
fruits,
vegetables and
grains)
Adequate fluid
intake/8
glasses/day or
20003000ml/day

Normal
frequency of
passing stool
varies from
twice daily to
once every
third or fourth
day
Prolonged bed
rest lack of
exercise and
inactivity
contribute to
constipation.
Increased fluid
intake make
soft formed
stool

Foods rich in
fiber helps to
increase normal
bowel
movement

12o gram/day is
recommended

NURSING CARE PLAN

Regular
meals/Successf
ul bowel
training relies
on routine

Persons
unaccustomed
to high fiber
diet may
experience
abdominal
Privacy of
discomfort and
defecation
flatulence; a
gradual
COLLABORATIVE increase in fiber
intake is
recommended
6. Teach use of
pharmacological These aid in
agents as
softening stools
prescribed by
and
the physician
stimulate rectal
such as
mucosa
suppositories

Evaluation: Expected short term outcome met; family is able to

verbalize measures that will prevent recurrence of constipation as evidenced
by stating drinking plenty of water, eating foods high in fiber, and
providing privacy when patient defecates.
Long term goal partially met patients bowel movement slightly improved as
measured by stool slightly softened. Patient still defecate fewer than 2x after
5days.

NURSING CARE PLAN

Problem 4: Disturbed Sleep Pattern related to

Patient Care Activities
Level of Prioritization: Low priority
03/22/2014

Date performed:

Reason: Its related to his current illness and needs to be attained in order for
the patient to have a normal sleep cycle
Goal: Patient will have a normal sleep pattern.
Cues
Subjective:
sige sya ug
mata2x
tungod sa
schedule sa
iyang tambal
ug mangihi
siya as
verbalized
by the
relatives.
Objective:
Awakening
earlier or
later than
desired
3 or more
night time
awakenings

Desired
Outcome
Short
term:
After 4
hours of
nursing
intervention
Patient will
appear
rested
Patient will
show an
improveme
nt in the
sleep
pattern
as
evidenced
by not
showing
irritability
and limited
yawning
.

Intervention
Independent:
1. Record number of
sleep hours and sleep
pattern. Note physical
or physiological
circumstances that
interrupt sleep

RATIONALE

Sleep pattern are

unique to each
individual

2. Modify the
The environment must
environment by
be conducive to
decreasing noise,
sleep.
comfortable
temperature, darkness,
closed door.
This will help enhance
3.Provide a relaxing
the sleeping comfort
activity before bedtime of patient..
such as A back rub,
providing pillows for
comfort, calming
music, or reading can
all help the patient
relax before sleeping

NURSING CARE PLAN

Irritability

Long term:

Yawning

After 24
hours of
Restlessness nursing
intervention
Eye bags
patient will
achieve
Altered facial optimal
expression
amounts of
(blank look,
sleep.
fatigued
appearance

Different drugs are

COLLABORATIVE
prescribed depending
4. Administer sedatives on whether the
as ordered
patient has trouble
.
falling asleep or
staying asleep

5. Organize nursing
care to provide
minimal interruptions
and allow for at least
two hours of
uninterrupted sleep.

To promote minimal
interruption in sleep
or rest.

Evaluation:

Expected short term outcome met; family is able to

verbalize measures that will prevent recurrence of constipation as evidenced
by stating drinking plenty of water, eating foods high in fiber, and
providing privacy when patient defecates.
Long term goal partially met patients bowel movement slightly improved as
measured by stool slightly softened. Patient still defecate fewer than 2 x
after 5days.

Student Nurse Signature:

Batican, Kryza dale

Chiong, Rejean

Tasani, Glydel

Monzolin, Jonalyn

Pabellan, Ruegine Kieth

NURSING CARE PLAN