Name: Kristine T.

Acasio Date: October 2, 2021

Clinical Instructor: Mrs. Charity Cajucom Elicano RN, MAN Section/Group: N32/Group 5

NURSING CARE PLAN

CUES DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Impaired physical Short - term Independent: ● Provides GOAL MET.

mobility may be goals: opportunity to
“I am having a hard related to loss of limb After 8 hours of ● Provide regular evaluate healing Short - term
particularly a lower nursing treatment of and note goals:
time moving some intervention, the After 8 hours of
extremity; pain or residual limbs. complications
certain parts of my patient will be nursing
discomfort; ● Round measurement unless covered by
body unlike before” perceptual able to: on a regular basis immediate intervention, the
as verbalized by patient will be able
impairment ● Restant limb with prosthesis.
the patient. ●Comprehension to:
elastic bandage ● Measurement is
of circumstances,
immediately done to estimate
treatment ●Understanding of
OBJECTIVE: ● Help the afflicted shrinkage to
regimes and individual situation,
limbs and unaffected ensure proper fit
security measures treatment regimen
-Reluctance to with specific range of sock and
●Keep the function and safety
of movement prosthesis.
attempt movement position as measures
exercises; ● Edema will occur
-Impaired demonstrated by ●Maintain position
● Provide, as specified, rapidly, thus
coordination lack of contracts of function as
trochanter rollers. delaying
evidenced by
-Decreased muscle ● Instruct patient to lie rehabilitation.
Long - term goals: absence of
strength prone position as ● Prevents
After 2 days of contractures
tolerated, at least contracture
Nursing
● V/S taken as twice a day with deformities, which
intervention, the Long - term goals:
follows: pillow under can develop
patient will be able After 2 days of
abdomen and rapidly and could
to: Nursing intervention,
T: 37.2 °C lower-extremity delay prosthesis
the patient will be
P: 80 residual limb usage.
● Demonstrat able to:
R: 17 e methods
BP: 100/80 and -Demonstrate or assist ● Prevents external ●Demonstrate
conduct with transfer rotation of techniques and
that allow techniques and use of lower-limb behaviors that
activities to mobility aids such as residual limb. enable resumption
be trapeze or a walker. ● Strengthens of activities; and
resumed; extensor muscle ●Display willingness
and Collaborative: and prevents to participate in
flexion contracture activities.
● Show ● Refer to of the hip, which
readiness rehabilitation team can begin to
to take part such as physical and develop within 24
in the occupational hours of sustained
events. therapy and malpositioning.
prosthetic ● Facilitates self-care
specialists. and patient’s
● Provide foam or independence.
flotation mattress. Proper transfer
techniques
Demonstrate or assist prevent shearing
with transfer abrasion/dermal
techniques and use of injury related to
mobility aids such as “scooting”
trapeze or a walker. ● Provides for
creation of
Collaborative: exercise and
activity program to
● Refer to meet individual
rehabilitation team needs and
such as physical and strengths and
occupational identifies mobility
therapy and functional aid to
prosthetic promote
specialists. independence.
● Provide foam or ● Reduces pressure
flotation mattress. on skin and tissues
than can impair
circulation,
potentiating risk of
tissue ischemia
and breakdown.