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    Clinical Instructor: Mrs. Ramon A. Galicia, RN: Krystlle Lyre G. Cordero 4Bcn San Beda College Nursing Care Plan

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     Assist patient in  To provide safety and ambulation with comfort during walker or crutches ambulation. as prescribed.  Assist patient in toileting as needed. Evaluation:  Evaluate patient’s  Evaluation of the ability to perform effectiveness of the self-care activities nursing interventions independently or will determine if goals with assistance. are met or if revisions  Evaluate if goals are needed. are met.

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    Clinical Instructor: Mrs. Ramon A. Galicia, RN: Krystlle Lyre G. Cordero 4Bcn San Beda College Nursing Care Plan

    Uploaded by

    starcordero
    12K views4 pages
     Assist patient in  To provide safety and ambulation with comfort during walker or crutches ambulation. as prescribed.  Assist patient in toileting as needed. Evaluation:  Evaluate patient’s  Evaluation of the ability to perform effectiveness of the self-care activities nursing interventions independently or will determine if goals with assistance. are met or if revisions  Evaluate if goals are needed. are met.

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    Self Care Deficit 2

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     Assist patient in  To provide safety and ambulation with comfort during walker or crutches ambulation. as prescribed.  Assist patient in toileting as needed. Evaluation:  Evaluate patient’s  Evaluation of the ability to perform effectiveness of the self-care activities nursing interventions independently or will determine if goals with assistance. are met or if revisions  Evaluate if goals are needed. are met.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    12K views4 pages

    Clinical Instructor: Mrs. Ramon A. Galicia, RN: Krystlle Lyre G. Cordero 4Bcn San Beda College Nursing Care Plan

    Uploaded by

    starcordero
     Assist patient in  To provide safety and ambulation with comfort during walker or crutches ambulation. as prescribed.  Assist patient in toileting as needed. Evaluation:  Evaluate patient’s  Evaluation of the ability to perform effectiveness of the self-care activities nursing interventions independently or will determine if goals with assistance. are met or if revisions  Evaluate if goals are needed. are met.

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    Download as doc, pdf, or txt
    of 4

    Krystlle Lyre G.

    Cordero
    Clinical Instructor: Mrs. Ramon A. Galicia, RN
    4BCN
    San Beda College

    NURSING CARE PLAN


    Patient’s Name: C.F
    Age: 15 years old
    Dx: Osteogenesis Imperfecta Fracture, closed complete middle 3rd femur right

    SCIENTIFIC NURSING
    ASSESSMENT DIAGNOSIS PLANNING RATIONALE EVALUATON
    RATIONALE INTERVENTION
    Subjective: Self-Care Due to Resources will Independent: The resources
     “Nahihirapa Deficit in limitations in the be identify  Establish rapport  To establish rapport on were identified
    n ako kumilos bathing/ individual’s which are on the client. the client. which are useful in
    lalo na sa hygiene,dressi ability to useful in  Monitor vital  To obtain the baseline optimizing the
    pagligo, ng/grooming, ambulate, he is optimizing the signs. data. autonomy and
    pagkain” as feeding and prevented from autonomy and  If in a typical  Observation of bathing independence of
    verbalized by toileting RT performing ADLs independence bathing setting for performed in an the patient in his
    the patient. Musculoskelet that allow her to of the patient the client, assess atypical bathing hygiene, dressing
    al Impairment manage her the client’s ability to setting may result in or grooming,
    Objective: Secondary to hygiene such as bathe self via direct false data for which feeding and in
     Inability to Fracture bathroom observation using use of a physical toileting.
    feed self Femur privileges, physical performance test
    independently bathing, clothing performance tests compensates to
     Inability oneself. for ADLs. provide more accurate
    to dress self  Provide health ability data.
    independently teaching on the  To provide adequate
     Inability client regarding the knowledge on the
    to bathe and proper way on client.
    groom self effective oral
    independently hygiene.
     To provide correct
     Inability  Explain the pattern of performing
    to perform procedure of proper the procedure.
    toileting bathing and hair
    tasks brushing on the  Individualized bathing
    independently patient. produces a more
     Inability  Individualize positive bathing
    to ambulate bathing by experience and
    independently identifying function preserves client
    of bath (e.g., odor, dignity. Client
    urine removal), aggression is increased
    frequency required with shower
    to achieve function, (especially) and tub
    and best bathing bathing. Towel bathing
    form (e.g., towel increases privacy and
    bathing, tub, eliminates need to
    shower) to meet move the client to
    client preferences, central bathing area;
    preserve client therefore it is a more
    dignity, make soothing experience
    bathing a soothing than either showering
    experience, and or tub bathing.
    reduce client  Adaptive devices
    aggression. extend the client’s
    reach, increase speed
     Teach use of and safety, and
    adaptive bathing decrease exertion and
    equipment (e.g., reduce caregiver
    long-handled burden (Chen et al,
    brushes, soap-on-a- 2000). Follow-up
    rope, washcloth teaching in the home
    mitt, wall bars, tub increases device use
    bench, shower and safety of bathing.
    chair, commode
    chair without pan in  To avoid the accident
    shower) and follow and for the patient to
    up in the home. practice the procedure.
     Guide and  To inform the patient
    support the patient of her responsibility as
    and let him perform an individual.
    the procedure.
     Encourage her to  To have cooperation
    take a bath and guidance coming
    everyday and be from relatives.
    responsible to his
    physical
    appearance.  Improved
     Inform the communication
    relatives to help the decreases aggression
    patient in doing her during bathing and
    duty everyday individualizes care.
    regarding his proper
    hygiene.
     Enhance
    communication  To provide comfort
    during bathing. during feeding and
    Allow the client to easy movement.
    participate as able
    in bathing. Smile  The need for privacy
    and provide praise is fundamental for
    for most
    accomplishments in patients.
    a relaxed manner.  Clothing that is
     Place patient in difficult to get in and
    optimal position for out of may
    feeding. compromise a
     Provide privacy patient’s ability to be
    during dressing continent.

     Assist patient in  Mechanical problems


    removing or may prohibit the
    replacing necessary patient
    clothing. from eating.

    Collaborative:
     Assure that  Collaboration and
    consistency of diet correlation of activities
    is appropriate for with interdisciplinary
    patient’s ability to team members
    chew and swallow, increases the client’s
    as assessed by mastery of self-care
    speech therapist. tasks.
     Request referrals
    for occupational and
    physical therapy.

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