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COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
Constipation related to lack of physical Short term: After 24 hours of nursing Long term: After two months of nursing
September activity interventions, patient will be relieved from interventions, patient will maintain a
29, 2016 discomfort of constipation. regular pattern of elimination.
INDIVIDUAL IMPLEMENTATION
PROBLEMS
(CUES)
APPROACHES RATIONALE
Subjective: 1. Check on the usual pattern of elimination, 1. It is very crucial to carefully know what is normal for each patient. The normal
Duwa nga including frequency and consistency of stool. frequency of stool passage ranges from twice daily to once every third or fourth
domingo en nga 2. Assess the patients activity level. day. Dry and hard feces are common characteristics of constipation.
han nga 3. Determine the patients need for privacy for 2. Sedentary lifestyle such as sitting all day, lack of exercise, prolonged bed rest and
elimination. inactivity contribute to constipation.
tinmakki, as 3. Defecating is a private thing. Most patients may have a hard time defecating
verbalized by 4. Consider the degree to which the patient away from the sense of privacy in their home.
brother. responds to the urge to defecate. 4. Ignoring the urge to defecate eventually leads to chronic constipation because
the rectum no longer senses or responds to the presence of stool. The longer the
Objective : 5. Assist patient to take at least 20 g of dietary stool stays in the rectum, the drier and harder it becomes. This will make the
Distended fiber (e.g., raw fruits, fresh vegetable, whole stool difficult to pass.
abdomen grains) per day. 5. Fiber adds bulk to the stool and makes defecation easier because it passes
Hypoactive bowel 6. Digitally eliminate the fecal impaction, if through the intestine essentially unchanged.
sounds necessary. 6. Stool that remains in the rectum for long periods becomes dry and hard;
7. Advise the patient and his family members debilitated patients, especially older patients, may not be able to pass these
to decrease fiber and increase fluid intake in stools without manual assistance.
the patients diet once he is able to orally 7. An individual needs only about 25 grams to 30 grams of fiber and 2-3 liters of
ingest food. water every day to soften the stool and encourage proper bowel function.
NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
SUBMITTED BY: Group Y Level III SUBMITTED TO:
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Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
Risk for Aspiration related to presence of Short term: After 8 hours of Long term: After 1 day patient will digest
September tracheostomy intervention, the patient will not food by gastric feeding without aspiration.
29, 2016
develop any of the risk of
complication.
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NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
Impaired skin integrity related to pressure Short term: Long term:
September ulcers secondary to prolonged immobility Within 2-3 days of nursing In a month, the occurrence of pressure
29, 2016 interventions, patient will experience ulcers will be avoided.
and unrelieved pressure.
healing of ulcer or reduce size of skin
ulcer.
NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
SUBMITTED BY: Group Y Level III SUBMITTED TO:
Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
DATE ASSESSMENT NURSING CARE PLAN (OBJECTIVE GOAL)
September Ineffective Airway Clearance related to Short term:After 24 hours the patient will Long term: After 1-2 days patient wil be fre
29, 2016 presence of endotracheal tube. maintain clear, open airways as evidenced of dyspnea.
by normal breath sounds, normal rate and
depth of respirations.
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9. Teach the patient the proper ways of may result in increased pulmonary secretions and respiratory fatigue.
coughing and breathing. (e.g., take a 8. Suctioning is needed when patients are unable to cough out secretions
deep breath, hold for 2 seconds, and properly due to weakness, thick mucus plugs, or excessive or tenacious
cough two or three times in succession). mucus production.
9. The most convenient way to remove most secretions is coughing. So it is
necessary to assist the patient during this activity. Deep breathing, on
the other hand, promotes oxygenation before controlled coughing.
NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
SUBMITTED BY: Group Y Level III SUBMITTED TO:
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1. Evaluate patients ability to perform 1. Restricted movement influences the capacity to perform most
Subjective: Activities of Daily Living efficiently and activities of daily living. Safety with ambulation is a significant
safely on a daily basis. matter. Determines strengths or insufficiency and may give
Maasi ak tani halos 2. Assess the strength to perform ROM to information regarding recovery. This helps out in preference of
haanen met nga maka- all joints. actions since different methods are used for the following: flaccid
3. Assess input and output record and and spastic paralysis.
kuti, as verbalized by the
nutritional pattern. 2. This assessment provides data on extent of any physical problems
watcher. 4. Assess the patients or caregivers and guides therapy. Testing by a physical therapist may be needed.
understanding of immobility and its 3. Pressure ulcers build up more rapidly in patients with a nutritional
Objective :
implications. insufficiency.
5. Monitor nutritional needs as they relate 4. The risk for effects of immobility such as muscle weakness, skin
- Limited range of motion
to immobility. breakdown, pneumonia, constipation, thrombophlebitis, and
- Limited ability to 6. Present a safe environment: bed rails up, depression are also to be considered in patients with temporary
perform gross motor bed in down position, important items immobility.
skills close by. 5. Good nutrition also gives required energy for participating in an
- Functional level: 3 7. Keep limbs in functional alignment with exercise or rehabilitative activities.
one or more of the following: pillows, 6. These measures promote a safe, secure environment and may
(requires help from
sandbags, wedges, or prefabricated reduce risk for falls.
another person and splints. 7. This avoids footdrop and too much plantar flexion or tightness.
device) 8. Provide foam or flotation mattress, water Maintain feet in dorsiflexed position.
or air mattress or kinetic therapy bed, as 8. These equipment decrease pressure on skin or tissues that can
necessary. damage circulation, potentiating risk of tissue ischemia or
breakdown and decubitus formation.
ACTUAL OUTCOME DATE AND TIME RECEIVED
NAME OF PATIENT: Patient Y ADMITTING DIAGNOSIS: Spinal cord injury, C6 level, bilateral
jump facet C6-C7
ADDRESS: Bayabas, Pico, La Trinidad, Benguet AGE: 50 DATE ADMITTED: March 10,2016
SEX: Male
SUBMITTED BY: Group Y Level III SUBMITTED TO:
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