CU-QMS-NURSING-0017
CAPITOL UNIVERSITY
COLLEGE OF NURSING
Name of Student: Marshin Thea Marie A. Celocia Date of Assignment: October 2, 2022
Name of Patient: LEGASPI, Carl Joseph Ward: ORTHO WARD Bed No. RED ROOM
NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) OBJECTIVES RATIONALE
Objective Data: Long Term: Independent: Goals met.
Patient undergone femoral Risk for Infection Related to After 8 hours of nursing Obtained vital signs. After 8 hours of
Skeletal Traction surgery Skeletal Traction as Evidenced by intervention, the patient will R: Febrile patient may indicate nursing intervention,
last September 25, 2022. Insertion of Pins on the Patient’s be able to: presence of infection. patient was able to
Exposed wound site. Left Femur. Achieve timely wound Assessed pin sites and skin areas, maintain infection-
Traction pins in placed on healing, and be free of presence of edema, drainage. free throughout
the left femur with 12 kg infection. R: May indicate onset of local wound and bone
attached counterweight. infections or tissue necrosis. fracture healing.
Heplock in placed. Instructed patient and significant
Patient is not allowed to take a others to wash hands properly.
bath due to the traction. R: To prevent spread of bacteria
Vital signs were as follows: and contamination.
Blood pressure - 100/70 Instructed patient not to touch the
mmHg insertion sites.
Pulse rate - 99 beats per R: Minimizes contamination.
minute Instructed patient to perform daily
Temperature - 36.2 degrees tepid sponge bath.
Celsius R: Alternative way for a patient
who cannot take a bath and for
daily hygiene.
Collaborative:
Referred to physician if symptoms of
fever, rashes, or foul smell occurred.
R: To further assess patient’s
condition.
Issue: 05 April 2006 Revision Code : 003
CU-QMS-NURSING-0017
CAPITOL UNIVERSITY
COLLEGE OF NURSING
Name of Student: Marshin Thea Marie A. Celocia Date of Assignment: October 2, 2022
Name of Patient: LEGASPI, Carl Joseph Ward: ORTHO WARD Bed No. RED ROOM
NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) OBJECTIVES
Independent:
Subjective Data: Impaired Physical Mobility Long Term: Vital signs monitored. Goals met.
“Inani rako permi, musakit usahay Related to Skeletal Traction. At the end of the shift, the R: To have baseline data and monitor for any At the end of the
ug pag gusto ko mulingkod patient will be able to: irregularities. shift, the patient
mugamit rako aning gabitay Demonstrate Determined the degree of immobility using ADLs. was able to
saakong tungod. Naara si mama mu techniques that will R: Serves as the basis of the level of care to be demonstrate
assist kung mangihi ko permi.” as enable resumption provided. techniques that
verbalized by the patient. of activities with Health teachings given: repositioning, ROM will enable
comfort. exercises, adequate rest periods. resumption of
Objective Data: To accept the R: To promote self to enable patient to resume normal activities with
Patient undergone femoral optimum possible activities without minding limitations he has. comfort; accept
Skeletal Traction surgery goals in the light of Encouraged significant others to use comfort the optimum
last September 25, 2022. limitations, measures like being involved in assisting and possible goals in
Skeletal traction in placed on physical and providing care. the light of
the left femur with pins emotional. R: To promote cooperation and support that can uplift limitations,
and 12 kg counterweight. patient’s disposition. physically and
Heplock in placed. Kept patient comfortable on bed and needs were emotionally.
Patient is immobile and can attended.
perform limited actions only. R: May enhance self-concept and decreases feelings of
Patient uses an overhead frustrations.
trapeze upon moving or
Dependent:
sitting around bed.
Administered pain reliever prescribed by the
Functional level of 2, which
physician (only if patient reports pain).
requires assistance from
R: To ease pain and discomfort.
other person.
Collaborative:
Referred to radiologist for further evaluation and
improvements of fractured bone.
R: To monitor the fractured bone by taking X-
ray test.
Issue: 05 April 2006 Revision Code : 003
CU-QMS-NURSING-0017
CAPITOL UNIVERSITY
COLLEGE OF NURSING
Name of Student: Marshin Thea Marie A. Celocia Date of Assignment: October 2, 2022
Name of Patient: LEGASPI, Carl Joseph Ward: ORTHO WARD Bed No. RED ROOM
NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) OBJECTIVES
Independent:
Subjective Data: Self-Care Deficit Related to Long Term: Assessed patient’s strength to accomplish ADLs Goals met.
“Naara si mama permi mutabang Physical Immobility. At the end of the shift, the efficiently and cautiously on a daily basis. At the end of the
nako kay dili kaayo ko maka atiman patient will be able to: R: ADLs Mobility Status is a 12 self-care item shift, the patient
sakong kaugalingon.” as verbalized Demonstrate optimal related to eating, bathing, grooming, dressing, was able to
by the patient. performance of toileting, meal preparation, cleaning, ambulation. demonstrate
ADLs or activities Guided patient in accepting needed amount of optimal
Objective Data: of daily living. dependence. performance of
Patient on bed with skeletal Maintain positive R: Patient may require help in determining safe ADLs;
traction on the left femur. attitude in nurse- limits of trying to be independent versus asking for maintained
Heplock is placed. patient interaction. assistance when necessary. positive attitude
Patient is immobile and is Reduce frustrations Presented positive reinforcement for all activities towards nurse-
dependent on other physical and self- attempted. patient
activities. discouragement. R: External resources of positive reinforcement may interaction; calm
Patient is shy upon nurse- promote ongoing efforts. and relaxed.
patient interaction. Advised significant others to promote
Patient requires assistance independence, but intervene when patient is not
from a person on the able to carry out self-care activities.
following activities: R: It can avoid harm with activities without causing
Dressing, Grooming, disappointment.
Cleaning, Toileting, Provided patient privacy during dressing.
Laundry, and Chair Transfer. R: Patient may be fearful of breaches in privacy.
Patient is only independent on
feeding.
Patient requires assistance with
a device (Overhead Trapeze)
and from a person on bed
mobility.
Issue: 05 April 2006 Revision Code : 003
