Colleen S.

De la Rosa
BSN IV
NURSING CARE PLAN
PT. GB, 12 y/o

Assessment’ Diagnosis Planning Intervention Evaluation

LONG TERM: NSG. Action Rationale
Subjective Self-Care Deficit After 8 hours of After 8 hours the
Data:”Tatlong araw na r/t musculoskeletal nursing interventions 1. Assessed ability 1. To determine interventions were met as
po akong hindi impairment aeb the patient will able to carry out ADL’s aspects of self-care evidence by:
nakakaligo dahil sa paa poor personal to: on regular basis that are problematic
ko.” As verbalized by the hygiene to patient.
patient. 2. Plan activities to 2. Energy >Patient identifies useful
>Patient identifies prevent fatigue conservation
Objective Data: during ADL’s increases activity resources in optimizing the
- With abrasion useful resources in tolerance and autonomy and
wound on left optimizing the promotes self-care.
foot independence.
3. Encourage 3. An appropriate
- Blood noted on autonomy and
independence, but level of assistive
elastic bandage independence. intervene when care can prevent >Patient demonstrates
- Dirty clothes patient cannot injury with activities lifestyle changes to meet
noted perform. without causing
>Patient demonstrates self-care needs.
- Unpleasant odor frustration.
noted lifestyle changes to 4. Use consistent 4. This helps patient
meet self-care needs. routines and allow organize and carry >Patient recognizes
adequate time for out self-care skills.
patient to complete individual needs.
>Patient recognizes tasks.
individual needs. >Patient safely executes
5. Wound cleaning 5. To prevent self-care activities to
 infections.
>Patient safely 6. Provide positive 6. Positive utmost capability.
reinforcement for reinforcement
executes self-care every enhances self-esteem
activities to utmost accomplishment and encourages
made. repetition of
capability. desirable behaviors.
7. Establish regular 7. A plan that
activities so the balances periods of
patient is rested activity with periods
before activity. of rest can help the
patient complete the
desired activity
without
undue fatigue and
frustration.