NURSING CARE PLAN

SCIENTIFIC
CUES NURSING DIAGNOSIS EXPLANATION OF THE OBJECTIVES INTERVENTION RATIONALE EXPECTED OUTCOME
PROBLEM (DIAGNOSIS)

Subjective: A knowledge deficit in Short term:  Instructed patient to To meet specific and basic After giving nursing
relation to healthcare request assistance when information and prevent intervention:
“Mahadlok ko operahan Anxiety related to After 30 minutes of
is a lack of information needed. further injury to the arm.
kay basin sakit.” As knowledge deficit needed for a thorough nursing interventions  Assist client in  The patient was
verbalized by the relieved by anxiety.
understanding of a Patient will relieve changing clothes.
patient. disease process and  Elaborated basic  The patient has basic
by anxiety. information regarding
recommended information regarding the
treatments and the surgical procedure that the surgical
Patient will have procedure.
Objective: ability to make basic information was explain from the
informed choices or regarding the surgeon.
- wearing arm sling on
carry out tasks in surgical procedure.
left arm
alignment with health
Vital signs taken: maintenance.
BP: 90/70
Temp: 35.9°C
HR: 88 bpm
RR: 21 cpm
O2 sat: 98%

SN: Glady Mae B. Lim Group 4

SCIENTIFIC
CUES NURSING DIAGNOSIS EXPLANATION OF THE OBJECTIVES INTERVENTION RATIONALE EXPECTED OUTCOME
PROBLEM (DIAGNOSIS)

Subjective: Left shoulder Short term:  Establish rapport to To gain the trust and After giving nursing
dislocation secondary the patient cooperation of the patient intervention:
“Sakit akong kamot inig Acute pain related to After 30 minutes of
to fall t/c closed  Instructed patient to and prevent further injury to
matandog” as shoulder dislocation fracture lower 3rd of nursing interventions request assistance when the affected part.  The patient was
verbalized by the relieved by pain.
the humerus secondary Patient will relieve needed.
patient. to fall  Assist client in  The patient was able
by pain. to ask for assistance
Objective: changing clothes.
 Instructed patient to when needed.
 Sling on the Left  The patient
do deep breathing when
arm moving. understood the
 Pain scale 5/10 instruction to move
 Instructed patient to
move slowly to prevent slowly.
Vital signs taken:
further injury and pain to
BP: 120/80
the arm.
Temp: 35.5°C
HR: 80 bpm
RR: 21 cpm
O2 sat: 98%

SN: Glady Mae B. Lim Group 4

SCIENTIFIC
CUES NURSING DIAGNOSIS EXPLANATION OF THE OBJECTIVES INTERVENTION RATIONALE EXPECTED OUTCOME
PROBLEM (DIAGNOSIS)

Subjective: Left shoulder Short term:  Establish rapport to To gain the trust and After giving nursing
dislocation secondary the patient cooperation of the patient intervention:
“Dili ko kalihok ug Altered physical After 30 minutes of
to fall t/c closed  Instructed patient to and prevent further injury to
tarong” as verbalized by mobility related to fracture lower 3rd of nursing interventions request assistance when the affected part.  The patient was
the patient. fracture dislocation as relieved by pain.
the humerus secondary Patient will needed.
evidenced by limited to fall  Assist client in  The patient was able
Objective: movement. regain/maintain to ask for assistance
mobility to the highest changing clothes. It ensures that blood and
Vital signs taken  Assisted patient when when needed.
possible level. oxygen continuously flow  The patient
BP: 100/60 he wants to lie down. throughout the body,
Long term: understood the
Temp: 35.5°C  Instructed patient to allowing every organ to instruction to move
HR: 85 bpm do deep breathing when function properly.
Patient will be able to slowly.
RR: 21 cpm moving.
move without  The patient was able
O2 sat: 99%  Instructed patient to
discomfort. to verbalize the
move slowly to prevent
reduces the spread of illness importance of proper
further injury and pain to
and risk of medical hygienic practices like
the arm.
conditions. bathing, proper hand
 Instructed patient to
make little movements to washing, and tooth
brushing.
the unaffected part to
promote circulation.
 Encouraged patient to
do proper hygiene.

SN: Glady Mae B. Lim Group 4