Nursing Care Plan 1st Priority

Assessment Nursing Diagnosis Objective Interventions Rationale Evaluation

Short Term Goal Short Term Goal
“Sakit jod kayo ni akong Acute Pain related to Independent
tuhud dugay ra” Joint degeneration and At the end of 2 hours  Monitor skin color  Detects early changes At the end of 2 hours nursing
“Ga sige og sakit labi na muscle spasm secondary nursing intervention the and vital signs that may usually intervention the patient was
gabie og kadlawon” to osteoarthritis patient will be able to altered acute pain able to verbalize non-
“7 ang ka sakit” verbalize non-  Provide  To identify pharmacological methods and
pharmacological methods information about aggravating and demonstrated. Goal’s met.
As verbalized by the that provide relief, comfort measures relieving factors.
patient. demonstrate use of such as back rubs, Heat reduces pain Long term Goal
relaxation techniques such use of heat and through
Objective as back rubs, proper deep cold packs to improved blood flow At the end of 3 weeks nursing
breathing exercise, use affected area to the area and intervention the patient was
 Expressive heat and cold packs to through the reduction able to report satisfactory pain
Behavior affected area to decrease of pain reflexes. Cold control, and uses
(restless, crying) pain. reduces pain, pharmacological and non-
 Facial Grimaced inflammation, and pharmacological strategies.
 Guarding Behavior Long Term Goal muscle spasticity by
 Radiating Pain decreasing the
 Pain scale of 7/10 At the end of 3 weeks release of pain-
With Vital Signs of: nursing intervention the inducing chemicals
 BP: 140/90 mmHg patient will be able to and slowing the
report satisfactory pain conduction of pain
 RR: 25 cpm
control at a level less than impulses.
 PR: 59 bpm
3 to 4 on a scale of 0 to 10  Encourage patient  Redirects attention
as evidenced by stable to perform relaxing and helps in muscle
vital signs. activities such as relaxation
deep breathing
exercises

 Advice the  Muscle spasms may

significant other to result from poor body
 assist patient in alignment, resulting
turning sides in increased
discomfort.
 Encourage patient  Calcium, phosphorus,
to take adequate and vitamin Dare
balance diet, low essential for bone
purine diet rich in formation, increase
calcium, bone density and
phosphorus and mass
vitamin D

Dependent Dependent
 To aid faster healing
 Provide medication through
therapies as pharmacological
prescribed by the approach.
physician.
Mefenamic Acid 500mg  Anti-Inflammatory,
analgesic, and
antipyretic activities
in order for the
muscle to be relax
and to relieve
moderate pain.
Nursing Care Plan 2nd Priority

Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation

“Mu sakit man akong tuhud
pag mo lihok ko. Pag wala
si tatay mag lisud ko, dili
kayo ko ka lihok”
As verbalized by the
patient.
Objectives:
 Alteration in gait
 Limited range of
motion
 Altered ADL
Can’t perform basic
activities such as bathing,
dressing and toileting
without assistance.
 Pain upon moving
 Altered mobility
 Facial grimace
noted
Level of Independence
(Standardized functional
scale):
 III: Requires
assistance or
supervision of
another person and
equipment or device
Impaired physical mobility
related to pain and
discomfort of the knee area
(joint pain), and decrease
muscle strength
Dependent
Short term goal:
At the end of 2 hours
nursing intervention the
patient will be able to
verbalize understanding of
situation and individual
treatment regimen and
safety measures.
Long term goal:
At the end of 1 month of
nursing Intervention the
patient will demonstrate Vitamin B- Complex
free of complications of
immobility, as evidenced Independent
by normal fluctuation of
vital signs during physical
activity, intact skin,
absence
of thrombophlebitis, normal
bowel pattern, and clear
breath sounds.
Short term goal:
 Established  Motivation and At the end of 2 hours
guidelines and goals cooperation are nursing intervention the
of activity with the enhanced if the goal was met, the patient
patient and/or SO patient participates was able to verbalize
such as position in goal setting. understanding of situation
changes, ambulation and individual treatment
and exercises. regimen and safety
measures
 Provide medication  Aids healing
therapies as through
prescribed by the pharmacological Long term goal:
physician approach
At the end of 1 month of
Prevents vitamin defiency nursing intervention the
due to poor diet and goal was partially met, the
osteoarthritis patient was able to
demonstrate free of
 Assess the client’s  Elevations in HR, complications of
vital signs after respiratory rate, and immobility as evidenced by
physical activity BP may be a normal vital signs, intact
function of skin, normal bowel pattern,
increased effort and and clear breath sounds
discomfort during
the performance of
tasks.
 Encourage the client  Increasing activity
to increase activity at home can be
as indicated. effective in
maintaining joint
function and
independence. A
balance must exist
between the client
 performing enough
activity to keep
joints mobile and
not taxing the joint
too much.

 Taught energy  These techniques

conservation reduce oxygen
techniques, such as consumption,
 Sitting to do task allowing a more
 Pushing rather than prolonged activity.
pulling
 Resting for at least
1 hour after meal

 Assist to do active  Muscular exertion

and passive range of through exercise
motion exercise promotes circulation
such as flexing both and free joint
extremities, head mobility,
tilts, shoulder strengthens muscle
movement, and so tone, develops
forth. coordination, and
prevents non-
functional
contracture.
Nursing Care Plan 5th Priority

Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation

Subjective: Short Term: Dependent: Short Term:
Deficient Knowledge  Provided mutual goal  This clarifies the
“Wala na jud ko kasabot related to misinterpretation At the end of the 2- setting with the patient. expectations of nurse At the end of the 2-hour
sa akong balatian Musamot of information hour intervention, the client  Let the patient shared and client. intervention, the client was
akong sakit ani.” will be able to participate in about what he knows  This can arouse able to participate in
learning process, exhibit and move to what he interest or sense of learning process, exhibited
“ Wa moy pulus ang mga increase interest and assume doesn’t know, being overwhelmed. increase interest and
tambal gang.” responsibility for own progressing from assumed responsibility for
learning by asking questions simple to complex. own learning. Goals met.
“Di nko ma ayo ani, maka and verbalize understanding
matay mani na sakit” of condition, disease process Independent:
and treatment. Long Term:
As verbalized by patient  Identified motivating  Motivation may be At the end of 4 months,
Long Term: factors for the positive or negative the client was able to initiate
Objective: individual. feedback. necessary lifestyle changes
At the end of 4 months,  Provided  To prevent overload. and participated in treatment
the client will be able to information relevant regimen.
 Verbalizing inaccurate identify relationship of signs to client’s condition.
information and symptoms to the disease  Provided positive  This could encourage
 Patient answers process and correlate reinforcement. continuation of efforts.
the question symptoms with causative  Stated objectives  To meet learner’s
misleading factors and initiate clearly in the client’s needs.
or incorrect necessary lifestyle changes terms.
information and participate in treatment  Provided an active  This promotes a sense
 Inaccurate follow regimen. role for the client in of control over the
through the learning process. situation and is a
instructions means for assimilation
 Exaggerated Conclusion and using new
and behaviour information.
 Agitated  Provided access  To answer questions
 Apathetic information for the and validate
contact person. information while in
distance.
Nursing Care Plan
Assessment
Not applicable for Risk
diagnosis.
Risk Factor:
 Age- 82 years old
 Use of assistive device-
Cane
 Osteoarthritis affecting
the knee
 Impaired balance
4th Priority
Nursing Diagnosis Objectives
Short Term:
Risk for Falls
At the end of the 2-
hour intervention, the client
will be able to verbalize
understanding of individual
causative factors and
identify interventions to
prevent or reduce risk of
fall.
Long Term:
At the end of 1 month,
the client will be able to
demonstrate behaviours and
lifestyle changes to promote
safe environment, and to
reduce risk factors and
protect self from injury.
Intervention Rationale Evaluation
Dependent: Short Term:
 Identified resources  For lifestyle At the end of the 2-hour
available to modification. intervention, the client was
individual. able to verbalized
understanding of individual
 Provide access to  To monitor drugs side causative factor and
medication and how effects, such as identified interventions to
it affects the patient. dizziness, headache prevent or reduce risk of
confusion that may infection.
Independent: causes disturbance to
balance and gait Long Term:
At the end of 4 months,
 Assist client with  Maintains and the client was able to
active and passive enhances muscle demonstrate techniques and
ROM exercises and strength, joint function, lifestyle changes to promote
isometrics as and endurance. safe environment.
tolerated.
 Instruct the client  Helps prevent
regarding safety accidental injuries and
measures: falls..
 Raised chairs and
toilet seat
 Use of handrails
 Accurate use of
mobility equipment
and wheelchair
safety.
 Assess muscle  To assess degree of
strength, gross and risk of falling, altering
fine motor coordination, gait and
coordination balance.
Nursing Care Plan 3rd Priority

Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation

Subjective: Imbalance Nutrition less Short term goal: Dependent: Short Term Goal
than body requirements
“Okay rman among related to decreased appetite At the end of 2 hours of  Taken a nutritional  Family members may At the end of 2 hours nursing
kina-on dri maam naa lay Secondary to physical nursing Intervention the history with the provide more accurate intervention the patient was
usahay na dili kayo ko limitations patient will be able to participation of details on the patient’s able to verbalize
ganahan og kaon kay sakit verbalize understanding of significant others. eating habits, understanding of significance
kung mu lihok” significance of nutrition to especially if patient of nutrition to healing
healing process and general has altered perception. process and general health
as verbalized by the health.
patient.
 Encouraged the patient  Good oral hygiene
Objective: or SO to provide good enhances appetite; the
Long term goal: oral hygiene before condition of the oral
 Poor Appetite and after meals. mucosa is critical to
 Poor muscle tone At the end of 3 weeks of the ability to eat. The
 Thin for age nursing intervention the oral mucosa must be
 Weight: 39 kgs patient will be able to : moist, with adequate
Height: 4’8 ft -Patient displays nutritional saliva production to
BMI: 18.2 below ingestion sufficient to meet facilitate and aid in the
normal or metabolic needs as digestion of food
underweight manifested by stable weight (Evans, 1992).
 Recent Weight and exhibits improved
Loss 2 kgs energy level  Ascertained healthy  Body mass index
-Patient takes adequate body weight for age (BMI) is a measure of
amount of calories or and height. Compute body fat based on your
nutrients. the Body mass index weight in relation to
of the client. your height, and
applies to most adult
men and women aged
20 and over.
Independent:

 Encouraged to eat well  This means eating a

with balaced diet of wide variety of foods
carbohydrates, Proteins in the right
and fat.Consider proportions, and
Purine Diet consuming the right
amount of food and
drink to achieve and
maintain a healthy
body weight.

 Consider six small  Eating small, frequent

nutrient-dense meals meals lessens the
instead of three larger feeling of fullness and
meals daily to lessen decreases the stimulus
the feeling of fullness. to vomit

 Weigh the patient as  Weighing is an

indicated assessment tool to
determine the
adequacy of nutritional
intake

 Encourage to drink  This it to provide

sufficient amount of proper hydration to the
fluids. Drink 8-10 body.
glasses a day.