POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Tilin, Alfredo Date of admission: January 01, 2017
Age: 46 Sex: male Civil Status: Married Diagnosis: spinal fracture
Occupation: driver Religion: Roman Catholic Ward: Medical Ward
Address: calinang, Davao City

DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
Jan 13, Subjective: Cognitiv Pain r/t Unpleasant After 5 hours of -encourage client to -alter patient present may Partially Goal Met
2017 sakit ayo ako e Spinal sensory and nursing alter his present on pain reduce of cannot feel the
@ likod perceptu fracture emotional intervention the so not to feel the pain. pain. After 5 hours of
8:00 pagmaglihok al experience a patient will be nursing intervention
AM ko, dili pud pattern rising from able to show -encourage patient to do -diversional activities the patient will able
ko kabaclay actual or signs of diversional activity also can altered the pain. to develop good
og tidog kay potential decreased pain as such as tacking, prognosis as
mag sakit described in evidenced by: reading. -to distraction attention evidence by:
As verbalized terms of damage. and reduced tension
by the client -decrease of pain -encourage use of -pain scale of 3
scale from 8 to 3 relaxation techniques -verbalization of feeling
Objective: such as focused about the pain such -no facial grimace
-pain scale of -no guarding breathing, imaging. concerns about thoughts.
8 behavior -absent of guarding
-facial -evaluate coping -provide for behavior
grimace upon -absent of facial abilities and to identify individualized physical
interviewing grimace areas of additional therapy of exercise
on client concerns. program
-general body -client will able
weakness promote body -promotes activity,
-guarding strength rather than passive, role
behavior and enhance sense of
noted control.
-moaning
-afebrile
noted

Name: Noelby jay D. Palamos Section & Year: BSN - III Rating: _______________
Reference: Nurses pocket guide by Doenges, Moorhouse & Murr
Criteria: Promptness (5%) _______ Objective of Care (10%) _______
Format/Neatness (5%) _______ Nursing Actions (40%) _______
Assessment (15%) _______ Evaluation (10%) _______
Nursing Diagnosis (15%) _______ Clinical Instructor: Lourdes Abecia, RN
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.
MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Tilin, Alfredo Date of admission: January 01, 2017
Age: 46 Sex: male Civil Status: Married Diagnosis: spinal fracture
Occupation: driver Religion: Roman Catholic Ward: Medical Ward
Address: calinang, Davao City

DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
Jan 13, Subjective: Activity- Activity Insufficient After/within 8 -provide comparative -evaluate client actual Partially goal met
2017 Dili ko exercise intolerance physiological or hours span of baseline and and perceived
@ naglihok pattern. r/t spinal psychological care patient will information about limitations and severity After/within 8 hours
8:30 lihok og dili fracture. energy to endure able to gain needed education or of deficit in light of of nursing
AM ko katindog or complete strength and intervention. usual status intervention the
sige lang jud required or increased patient will able to
ko og higda desired daily mobility as -symptoms may be -note client report of develop good
as verbalized activity. evidenced by: result of or contribute to weakness, fatigue, pain prognosis as
by the client: intolerance of activity difficulty evidenced by:
-increased range accomplishing task
Objective: of motion. -develop individual -increase activity
-afebrile appropriate therapeutic -provide referral to range of motion
-fatigue -improve body regimens other discipline such as
-general body strength. exercise -develop good
weakness -indicated need to alter mobility on bed
-poor skin -respiration will activity level -instruct client in
integrity be on normal monitoring response to Improve sings of
-limited range. -both activity tolerance activity energy
movement and health status may
noted -able to show improve with -plan for progressive
-respiratory good energy. progressive training. increase of activity
distress noted level participation in
28 exercise training

Name: Noelby jay D. Palamos Section & Year: BSN - III Rating: _______________
Reference: Nurses pocket guide by Doenges, Moorhouse & Murr
Criteria: Promptness (5%) _______ Objective of Care (10%) _______
Format/Neatness (5%) _______ Nursing Actions (40%) _______
Assessment (15%) _______ Evaluation (10%) _______
Nursing Diagnosis (15%) _______ Clinical Instructor: Lourdes Abecia, RN
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.
MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Tilin, Alfredo Date of admission: January 01, 2017
Age: 46 Sex: male Civil Status: Married Diagnosis: spinal fracture
Occupation: driver Religion: Roman Catholic Ward: Medical Ward
Address: calinang, Davao City

DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
Jan 13, Subjective: na Activity- Impaired Limitation in After/within 8 -identify potential -note factors affecting Partially Goal met
2017 gulo ko sa exercise physical independent, hours of nursing impairment and current situation and
@ akong gi bati pattern mobility r/t purposeful intervention determines type of potential time involved After/within 8 hours
9:00 kay dili ko spinal physical patient will show intervention of nursing
AM kalahok segi fracture movement of the signs of -observe movement intervention the client
lang ko og body or of one or improvement as -note any in when client is unaware will able to develop
higda. more extremities evidence by: congruencies with of observation. good prognosis as
reports of abilities evidenced by:
Objective: -increase range -instruct in use of side
motion on bed -position changes, rails overhead trapeze, -Increase range
-Limited transfer, and ambulation roller pads, cane. motion on bed
range of -able to move
motion noted side to side -maintain position of -support affected body -increase movement
-Afebrile function and reduce risk parts or joint using to promote muscular
noted -promote of pressure ulcers pillows, rolls, foot integrity
-decrease muscular support.
muscular integrity -promote -promote sings of
impairment independences and -demonstrate use of energy.
noted enhances safety standing aids and
-Decreases mobility devices and
range of have client care.
motion noted.

Name: Noelby jay D. Palamos Section & Year: BSN - III Rating: _______________
Reference: Nurses pocket guide by Doenges, Moorhouse & Murr
Criteria: Promptness (5%) _______ Objective of Care (10%) _______
Format/Neatness (5%) _______ Nursing Actions (40%) _______
Assessment (15%) _______ Evaluation (10%) _______
Nursing Diagnosis (15%) _______ Clinical Instructor: Lourdes Abecia, RN