ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective data: Impaired After 2-3 months INDEPENDENT At end of 3 months of

“Hindi ko maigalaw
of nursing  Monitor the vital signs. To serve as the nursing interventin the
physical intervention, the baseline data of client. patient was able to:
ang binti ko ”, as patient will be:  Limit movement and encourage R.O.M.
mobility
verbalized by the
 Verbalize
exercises. Muscles will rest to promote  Verbalize
patient related to loss understanding strength and joint motion understanding of
of the situation  Determine diagnosis that contributes to the situation and
of integrity of and individual immobility. To identify contributing factors individual
Objective data: treatment  Determine the degree of immobility in relation treatment
bone structure regimen and to suggested scale. To assess functional regimen and
 limited safety measures.
safety mobility
range
(fracture) measures.  Assist client reposition self on a regular  Participate in
of motion ADLs and
 slowed  Participate in schedule. To promote optimum level
ADLs and of function and prevent complications desired activities
movement
desired  Promote w e l l n e s s a n d provide emotional  Maintain and
 limited increase strength
ability to activities support in the process. To establish goal
 Maintain and and function
perform and provide positive attitude towards the of affected part.
gross and increase client.
strength and
fine motor
function  Support the affected body part using pillows.
 with cast on To maintain position and function and
left leg of affected
part. reduce risk of pressure ulcers.

Reference: Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales

 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective data: Risk for After 2-3 days of INDEPENDENT At end of 2-3 days of
"Hindi ako umakyat Disuse
nursing intervention,  Encourage active range of motion exercises. nursing interventin the
the patient will be: Active ROM helps keep muscles in current patient was able to:
ng hagdan nang Syndrome strength and promotes circulation. Mild
hindi humihinto at Not develop any skin activity also helps burn unneeded calories.
related to Not develop any skin
nagpapahinga at break down or other  Provide support to edematous areas, e.g., elevate break down or other
maging humihingal decreased evidence of the feet on foot stool when sitting. Elevating the evidence of the
kahit na naglalakad complications of dependent area assists with decreasing tissue
activity complications of
lang ng normal”, as immobility. pressure and promoting fluid return to the immobility.
resulting from venous system and the heart.
verbalized by the However,since the risk
inadequate  Provide step-by-step cuing for each motor factors remain, the care
patient
activity during exercise or ADLs. As-needed plan will be ongoing
Objective data: balance reminders help the client recall what to do
 Inability to oxygen supply next
move  Use visual aids to facilitate learning how to
including perform exercises. Some people have better
bed visual memory than auditory memory
mobility,  Offer options, explain rationale for type of
transfers, exercise and protocol to client, and allow him to
and make choices that appeal to him and that address
ambulation his needs. If the client understands what the
 Inability to reasons are for activity, he can make good
perform choices
action as COLLABORATIVE
instructed  Collaborate with physical, occupational, and
 Limited recreational therapists in developing and
ROM executing an individually tailored exercise
 Reluctance program. This client will need a
to attempt multidisciplinary approach to his care. Each
movement member contributes from his or her area of
expertise

Reference: Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales

 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective data: Acute Pain related After 2 hours of nursing INDEPENDENT After 2 hours of nursing
“Pakiramdam ko
to inflammatory intervention, client will  Place pillows, sandbags, trochanter rolls, intervention, client verbalized
yung mga joints ko and splint. Rests painful joints and
masakit tuwing pag process and be able to verbalize pain is maintains neutral position. Use of splints pain was controlled with pain
gising ko ang can decrease pain and may reduce
destruction of the relieved from 8/10 to scale of 5/10.
umaga"”, as damage to the joint.
verbalized by the joint 2/10.  Provide gentle massage.
patient Promotes relaxation and reduces
muscle tension.
 Apply warm, moist compresses to affected
Objective data: joints several times a day. Heat
promotes muscle relaxation and
 Pain Scale: mobility, decreases pain, and relieves
8/10 morning stiffness.
 Guarding or  Encourage frequent changes of position.
protective Assist client to move in bed, supporting
behavior affected joints above and below.
 Facial Prevents fatigue and joint stiffness.
grimacing Stabilizes joint, decreasing joint
movement and associated pain
COLLABORATIVE
 celecoxib (Celebrex®) 100 mg/cap, 1
capBID, PO as prescribed by the
physician. This medication inhibits
the enzyme COX-2. This enzyme is
required for the synthesis of
prostaglandins, but is less harmful to
the stomach and the kidneys. May
take celecoxib with or without food
intake.

Reference: Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales

 EMILIO AGUINALDO COLLEGE
Congressional Road, East Avenue, Burol Main, Dasmariñas City, Cavite 4114
SCHOOL OF NURSING

NCM-104 CARE OF CLIENTS WITH PROBLEMS IN

INFLAMMATORY AND
IMMUNOLOGIC RESPONSE, PERCEPTION, AND COORDINATION

BSN – 3 / GROUP 2

Musculoskeletal
Nursing Care Plan

Submitted by : JORELIEGH ROSE D. GARCIA

Submitted to: CONCEPCION L. BENALIZA RN, MAN

DATE: MAY 16, 2019