ACTUAL NURSING CARE PLAN

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired physical Trauma At the end 6hrs. of > Determine > To identify After 6hrs. of
mobility related to (Vehicular nurse-patient diagnosis that contributing nurse-patient
“Hindi ko loss of integrity of accident) interaction and contributes to factors interaction and
maigalaw ung bone structures intervention, the immobility. intervention, the
binti ko ”, as (hip dislocation) Hip Dislocation on patient will: patient has:
verbalized by the left hip > note situations > cause it may a.) Verbalized
patient a.) Verbalize such as fractures restrict movement understandin
bleeding from understanding g of the
Objective: damaged ends of of the situation > determine the > to assess situation and
surrounding tissue and individual degree of immobility functional mobility individual
>limited range of treatment in relation to treatment
motion regimen and suggested scale regimen and
stimulates safety safety
>slowed inflammatory measures. > determine > to assess measures.
movement response b.) Participate in presence of presence of b.) Participated
ADLs and complications complications in ADLs and
>limited ability to increased capillary desired related to immobility desired
perform gross permeability activities (pneumonia, activities
and fine motor c.) Maintain elimination c.) Maintained
fluid and cellular position of problems, position of
> with metal rod exudation function and decubitus) function and
on left leg skin integrity > to promote skin integrity
pain as evidenced > Assist client optimum level of as evidenced
>Functional by absence of reposition self on a function and by absence
Level: 3 impaired physical decubitus regular schedule. prevent of decubitus
mobility ulcers complications ulcers
d.) Maintain and d.) Maintained
increase > to maintain and
strength and > Support affected position and increased
function of body part using function and strength and
affected part. pillows. reduce risk of function of
pressure ulcers. affected part.

> It promote well-

> Encourage being and
adequate intake of maximizes energy
fluids/nutritious production
foods
 POTENTIAL NURSING CARE PLAN

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for infection Trauma At the end of the >Note risk factor for >To assess After 6hr nurse-
related to wound (Vehicular 6hr nurse-patient occurrence of infection causative/ patient interaction
secondary to accident) interaction and contributing and intervention
fracture intervention the factors the patient has
Hip Dislocation on patient will:
left hip >Observe for localized >To assess for a.) identified
a.) Identify signs of infection infected sites interventions to
Objective: bleeding from interventions to . prevent/reduce
(+) presence of damaged ends of prevent/reduce >Stress proper hand- >A first line risk of infection
wound, soaked surrounding tissue risk of infection hygiene by all defense against
wound dressing caregivers bet. healthcare- b.) Achieved
b.) Achieve timely Therapies/clients. associated timely wound
wound healing; infections healing; be
open reduction be free of free of purulent
and internal purulent >Recommend routine >To reduce drainage or
fixation drainage or or body shower/scrub bacterial erythema;
(wound in metal erythema; when indicated colonization
rod incision) c.) Been afebrile
c.) Be afebrile as >Change surgical or >To prevent as evidenced
evidenced by other wound infection by the normal
the normal dressings, as V/S.
Risk for infection V/S. indicated, using
proper technique for
changing or disposing
of contaminated
materials

>Review individual >To promote

nutritional needs, wellness.