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Stroke CP - NURSING CARE PLAN ASSESSMENT Subjective Hindi...

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NURSING CARE PLAN
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ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Subjective: “Hindi siya makatagilid sumasakit daw ung bali niya sa may bewang kapag gumagalaw” as verbalized by the sn of the patient. Objective: Impaired ability to turn side to side Impaired ability to move from supine to sitting vise versa. (+) presence of pelvic fracture (+) General weakness Tremors noted on left arm and hands > Impaired bed mobility related to pain secondary to musculoskeletal impairment. Trauma (slipping) bone fracture at pelvic bone Disruptions of periosteum and blood vessels Destruction if tissue Bleeding occurs Pain Impaired bed mobility After the rotation and nursing intervention the significant other of the patient will: a. Verbalize understanding of the situation /risk factors, individual therapeutic regimen and safety measures. b. Demonstrate techniques/ behaviors that will enable safe repositioning c. Maintain position of function and skin integrity of the patient as evidenced by absence of contractures, foot drop, decubitus, etc. determine diagnoses that contribute to immobility (e.g. fractures, hemi/para/tetra/q uadripegia) Note individual risk factors and current situation, such pain, age, general weakness, debilitation Determine perceptual/ cognitive impairment to follow directions Determine functional level classification Note presence of complications related to immobility Observe skin for reddened areas/shearing. Provide appropriate pressure to relief Provide regular skin care if appropriate Assist with activities of hygiene, toileting, feeding, as To identify causative/ contributing factors. To assess patients functional ability To reduce friction, maintain safe skin/tissue pressures and wick away moisture To prevent complications To promote optimal level of functioning After the rotation and nursing intervention the significant other of the patient will: a. Verbalize understanding of the situation /risk factors, individual
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