XI.

NCP Priority
List of Nursing Diagnosis Rank
Impaired Physical Mobility 1
Disturbed Body Image 2.5
Situational Low Self – Esteem 2.5
Powerlessness 3

XII. Nursing Care Plan

Nursing
Cues Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Impaired Physical Short Term Goal Independent Short Term Goal
 “Masakit pa Mobility related to After 8 hours of effective  Provide stump care on a routine  Provides opportunity to Goal partially met:
kasi kaya loss of digits nursing intervention: basis (e.g., inspect area, cleanse evaluate healing and After 8 hours of
hindi ko pa secondary to pain  Patient will verbalize and dry thoroughly, and rewrap note complications, wrapping effective nursing
magamit & discomfort as understanding on the stump with elastic bandage or air stump controls edema intervention:
yung kamay evidenced by fear health teaching given splint)  Patient verbalized
at paa ko, of attempting by discussing his  Assist with specified ROM  Prevents contracture understanding on
kaya nariyan movement and condition, treatment exercises beginning early in deformities, which can the health teaching
yung asawa guarding behavior plan, activities and postoperative stage. develop rapidly and could given but was not
ko para on the affected safety precautions delay prosthesis usage. able to discuss
tulungan site prescribed  Encourage active/isometric  Increases muscle strength to everything included
ako.  Patient will verbalize exercises for upper torso and facilitate transfers/ambulation  Patient verbalized
Kadalasan understanding on the limbs. and promote mobility and understanding on
siya nadin importance of more normal lifestyle. the importance of
gumagawa resuming his ADLs  Instruct patient to lie in prone  Strengthens extensor muscles resuming his ADLs
ng mga despite his condition position as tolerated at least twice and prevents flexion despite his condition
bagay kasi  Patient will verbalize a day with pillow under abdomen contracture of the hip, which  Patient verbalized
hindi ko pa understanding on and lower-extremity can begin to develop within 24 understanding on
kaya” as how important transfer hr of sustained malpositioning. how important
verbalized by techniques and the transfer techniques
 Demonstrate/assist with transfer  Facilitates self-care and
the patient use of mobility aids and the use of
techniques and use of mobility patient’s independence.
by discussing proper aids, e.g., trapeze, crutches, or Proper transfer techniques mobility aids but still
Objective: transfer techniques prevent shearing learning the proper
walker.
 Limited range and what mobility aids abrasions/dermal injury transfer techniques
of motion is applicable to related to “scooting.” and the right
 Guarding him/according to his mobility aid
 behavior on condition  Assist with ambulation  Reduces potential for injury. applicable to his
the affected  Patient will show an Ambulation after lower-limb condition
site interest and amputation depends on timing  Patient shown an
 Pain that willingness in . of prosthesis placement. interest and
ranges from 6- participating in   Provide foam/flotation mattress.  Reduces pressure on willingness in
8 when being activities that will skin/tissues that can participating in
touched or improve his mobility impair circulation, potentiating activities that will
during wound  Patient will perform risk of tissue improve his mobility
cleaning simple specified ROM ischemia/breakdown  Patient is still
(affected site) exercises learning the simple
demonstrated by the specified ROM
nurse Collaborative exercises
  Refer to rehabilitation team  Provides for creation of demonstrated by
Long Term Goal exercise/activity program to the nurse
At least 24 hours before meet individual needs and
hospital discharge: strengths, and identifies Long Term Goal
 Patient will perform mobility functional aids to Goal partially met:
physical activity promote independence.. 24 hours before
independently hospital discharge:
 Patient will perform his  Patient is now
ADLs independently performing physical
or within limits of activity
disease independently
 Patient together with  Patient is now
SO will demonstrate partially performing
transfer technique his ADLs
uses, to ensure safety independently due to
by minimizing the pain that still
potential risk for injury affect his range of
 Patient will use motion
assistive/mobility  Patient together with
devices according to SO demonstrated
his condition (e.g. the right transfer
wheelchair) technique to ensure
safety by minimizing
potential risk for
injury
 Patient used
assistive/mobility
devices which is
 wheelchair that
improve his self-
independence

Nursing
Cues Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Disturbed Body Short Term Goal Independent Short Term Goal
 “Nahihiya na Image related to After 8 hours of  Acknowledge and accept  Acceptance of these feelings Goal unmet:
akong makita loss of digits and effective nursing expression of feelings of as a normal response to what After 8 hours of
ng ibang tao alteration in self – frustration, dependency, has occurred facilitates effective nursing
intervention:
o ng mga perception as anger, grief, and hostility. Note resolution. It is not helpful or intervention:
 Patient will verbalize
kaibigan ko evidenced by fear withdrawn behavior and use possible to push patient before  Patient is still in
of reaction by attempt to learn
baka sabihin of denial. ready to deal with situation. the process of
others, verbal coping strategies to
sakin ‘Oh, Denial may be prolonged and accepting himself
response of adjust to a new reality 
pre! Dati ang be an adaptive mechanism
perceptions that  Patient will verbalize
ganda ng because patient is not ready to Long Term Goal
lakad mo reflect an altered attempt to recognize
cope with personal problems. Goal partially met:
anong view of self-body self-sabotage and
 Recognize the normalcy of  Experiencing stages of grief 24 hours before
nangyari appearance; body accept help from
response to the actual or over loss of a body part or hospital discharge:
sayo bakit function; and everyone around him
perceived change in body function is normal and typically  Patient is
naka wheel body structure.  The patient will involves a period of denial, the somehow able to
verbalize attempt structure or function.
chair kana!”” length of which varies among cope in his new
as verbalized identify irrational individuals. reality but in
by the patient beliefs and use new terms of
 Patient and SO tend to deal
 “Paki coping strategies to  Set limits on maladaptive
with this crisis in the same enhancing his
ramdam ko enhance perception behavior. Maintain nonjudgmental
way in which they have dealt coping strategies,
nabawasan about body image.  attitude while giving care, and
with problems in the past. patient still needs
kakayahan help patient identify positive
Staff may find it difficult and further guidance
ko dahil sa Long Term Goal behaviors that will aid in recovery.
frustrating to handle behavior and education
nangyari At least 24 hours before that is disrupting and not  The patient is still
sakin” as hospital discharge: helpful to recuperation but learning on how
verbalized by  Patient will verbalize should realize that the he will identify
the patient learnings on how he behavior is usually directed his irrational
 “Noon enhanced his coping toward the situation and not beliefs effectively.
mahilig ako by discussing his the caregiver. He is still
mag ayos strategies to adjust to  It is worthwhile to encourage enhacing his
kasi a new reality  the patient to separate techniques to
 Support verbalization of positive
pakiramdam  Patient will verbalize feelings about changes in cope with the
or negative feelings about the
ko ang linis recognizition of self- body structure or function from stress due to his
 ko pero sabotage and accept actual or perceived loss. feelings about self-worth. condition and
ngayon help from everyone Expression of feelings can slowly accepting
hindi ko around him enhance the patient’s coping his negative
alam, baka  The patient will strategies. perception about
ang panget verbalize learnings on  The more noticeable the his body image.
ko na” as how he identify change in body structure or
verbalized by irrational beliefs, function, the more anxious the
 Assist the patient in incorporating
the patient discuss what patient may have about the
actual changes into ADLs, social
strategies he use to response of others to the
life, interpersonal relationships,
Objective: cope and disscuss change. Opportunities for
and occupational activities.
 Verbalization how he enhance his positive feedback and success
of negative perception about his in social situations may hasten
feelings about body image adaptation.
body  Positive remarks by the nurse
 Decreased may encourage the patient
motivation for develop more positive
self-care  Exhibit positive caring in routine responses to the changes in
 Indecisive activities. his or her body.
self-  This enhances trust and
deprecating rapport between patient and
remarks nurse.
 Sadness  Be realistic and positive during
treatments, in health teaching,
and in setting goals within
limitations.  This enhances trust and
 Provide hope within parameters rapport between patient and
of individual situation; do not give nurse.
false reassurance.  Words of encouragement can
 Give positive reinforcement of support development of
progress and encourage positive coping behaviors.
endeavors toward attainment of
rehabilitation goals.  A good conversation provides
 Give positive reinforcement of ongoing support for patient
progress and encourage and family.
endeavors toward attainment of
rehabilitation goals.  Support groups
 Provide support group for SO. promotes ventilation of
Give information about how SO feelings and allows for more
can be helpful to patient. helpful responses to patient.
  Reinforcing teaching can help
 Provide thorough teaching and patient achieve self-care.
complete aftercare instructions
for the patient.  The patient experiencing a
 Discuss with patient about the body image change needs
normalcy of body image new information to support
disturbance and the grief cognitive appraisal of the
process. change.
 Adaptive behaviors help the
 Teach the patient adaptive patient compensate for the
behavior (e.g., use of adaptive actual changed body structure
equipment, wigs, cosmetics, and function.
clothing that conceals the altered
body part or enhances remaining
part or function, use of
deodorants).  Adaptive behaviors help the
 Support the patient in identifying patient compensate for the
ways of coping that have been actual changed body structure
beneficial in the past. and function.

 Lay people in similar situations

Collaborative offer a different type of
 Refer the patient and caregivers support, which is perceived as
to support groups composed of helpful
individuals with similar  These are helpful in identifying
alterations. ways/devices to regain and
 Refer to physical and maintain independence.
occupational therapy, vocational Patient may need further
counselor, psychiatric counseling, assistance to resolve
clinical specialist psychiatric persistent emotional problems.
nurse, social services, and
psychologist, as needed.