CHINESE GENERAL HOSPITAL COLLEGE OF NURSING

NURSING CARE PLAN

Name: Boy M AGE: 9 y/o DIAGNOSIS: post – debridement and arthrothomy of the left leg

ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: SHORT TERM INDEPENDENT SHORT TERM
Client’s relative Knowledge deficit Client’s relatives may After 30min of health teaching, - Assess grandmother’s level of - Provide comparative baseline Goal was met
verbalized: related to patient’s grandmother will be anxiety related treatment and provide information about As evidenced by:
have knowledge
able to know the importance of needed
unfamiliarity with deficit; defined as a plans and possible sepsis of a. Patient’s
“Gumagaling naman ang proper and active participation in the client. education/intervention
information grandmother was
lack of cognitive alleviating her granddaughter’s regarding quality of life.
mga sugat ng apo ko sa resources able to state 3
information or condition as evidenced by: - health teaching
mga dahon n itinatapal ways of the proper
psychomotor skills - discuss the different management of
ko.”
EXPECTED OUTCOME
required for health disease process inflammation of her
- State at least 3 ways of including the signs and grandson’s left leg
“Dati ganyan lang recovery,
the proper management symptoms - Provide information to the
- discussed that her
naman nawawala na maintenance, or of inflammation of her client’s grandmother so as to
- discuss the possible grandson could not
yung pamamaga ng binti health promotion. grandson’s left leg. equip her with knowledge
restriction in activity go to school for a
niya” regarding the proper techniques
because of her condition moment until her
- Identify alternative ways of care to an inflamed limb.
- teach on proper skin and grandson’s leg gets
“Yan lang din ang of managing pain aside
limb assessment well.
nakapagpagaling dun sa from medical aspect - Was able to identify
- demonstrate proper pain
mga tao sa probinsya that would alleviate the normal skin tone and
relief and anti-
discomfort temperature during
namin.” inflammatory regimen to
LONG TERM limb assessment.
the relatives and
- after 2 weeks of
significant others. - demonstrated proper
nursing intervention leg elevation so as to
- demonstrate proper
client’s grandmother will control pain
splinting techniques
be able to perform inflammatory
 proper leg care as - To prevent overexertion process of the leg
evidenced by: secondary to disease
- To reduce fatigue
- Assist in adjusting activities process.
EXPECTED OUTCOME - Gradually increase exercise
- To enhance ability to
- aseptic way of leg care and activity LONG TERM
participate in activities
- Maintain the affected - Promote comfort measures Goal was met as evidenced
leg free from any and provide for relief by:
unwanted pressure and a. client’s
ulceration. COLLABORATIVE grandmother was
- To have continuity of care
- Coordinate with the family in able to perform
continuous monitoring of inner-to-outer way
activity of cleaning the
affected leg and
allowed adequate
tightness on the
elastic bandage
applied to the long
leg posterior mold.
b. Was able to
demonstrate pain
relief exercise
through elevation of
the affected leg
c. Was able to
maintain client’s leg
free from any
unwanted pressure