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Nursing Care Plan

Assessment Diagnosis Planning Implementation Evaluation

Objective: Slipped on the floor Self care deficit: Ô ort term: after 4 Interventions Rationale Ô ort term: after 4
î Presence of self-feeding deficit hours of nursing -determine existing -for baseline data hours of nursing
balance skeletal Fracture of and self-toileting intervention, the conditions/extremes intervention, the
traction subtrochanteric deficit. client will be able to of age/developmental client was able to
î Inability to femur identify individual level affecting ability identify individual
handle utensils; Diagnosis: fracture areas of of individual to car e areas of
get food onto Balance skeletal closed complete weakness/needs. for own needs. weakness/needs.
utensil safely, traction displaced
bring food from subtrochanteric -note concomitant -for easier
a receptacle to Body weakness, femur. medical problems identification of
the mouth. pain that may be factors proper nursing care
î Inability to for care.
prepare food for Bed rest
ingestion -determine individual -to know what the
î Inability to wash Self care deficit: strengths and skills of client can do and
body/body parts feeding and the client cannot
î Inability to dry toileting
body. Long term: after 2 -establish -to gain Long term: after 2
days of nursing ³contractual´ cooperation days of nursing
intervention the partnership with intervention the client
client will be able to client¶s SO. was able to
demonstrate demonstrate
techniques/lifestyle -arrange for assistive -to help/assist client techniques/lifestyle
changes to meet devices as necessary to move changes to meet
self-care needs. self-care needs.
-assist/support family -to enhance
with alternative likelihood of finding
placements as individually
necessary appropriate
situation to meet
client¶s needs


Assessment Diagnosis Planning Implementation Evaluation
Ôubjective: Slipped on the floor Impaired physical Ô ort term: Interventions Rationale Ô ort term:
³di na siya mobility related to After 4 hours of -note decrease motor -to determine After 4 hours of
bumabangon, Fracture of musculoskeletal nursing intervention agility clients limitation to nursing intervention
nahihirapan umupo subtrochanteric impairment. the client will be able his/her ROM the client was able to
saka nanghihina´ as femur to verbalize verbalize
verbalized by the SO of Diagnosis: fracture understanding of -note situation such -to help us identify understanding of
the client. Balance skeletal closed complete situation/risk factors as fracture, surgery, the correct nursing situation/risk factors
traction displaced and individual etc. that may restrict intervention and individual
subtrochanteric treatment regimen movement treatment regimen
Objective: Body weakness, femur. and safety measure. and safety measure.
î Presence of pain -determine presence -to identify further
BST of complications nursing care to be
î On bed Bed rest related to immobility done.
î Limited ROM
î Difficulty turning Impaired physical Long term: -assist client -to help the client Long term:
mobility After 2 days of reposition self on move and exercise After 2 days of
Classification 2: nursing intervention regular schedule from time to time nursing intervention
-requires help from the client will be able dictated by SO the client was able to
another person for to demonstrate demonstrate
assistance, supervision techniques/behavior -instruct use of -for assistance to techniques/behavior
or teaching that overhead trapeze position changes that
enable/resumption enable/resumption of
of activities. -schedule activities -to reduce fatigue activities.
with adequate rest
periods during the