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NURSING CARE PLAN

Assessment Nursing Scientific Planning Implementation Scientific Rationale Evaluation


Diagnosis Explanation

Subjective Data: Impaired Klippel- After 3 days of * Assess for -Identifying barriers Goal Met
May bukol na ang Physical Trenaunay nursing impediments to to mobility guides After 3 days of
paa nya Mobility syndrome is a intervention, the: mobility. design of an optimal nursing
pagkapanganak ko related to rare condition treatment plan. intervention, the:
sa kanya, as congenital that is typically 1. Patient
stated by the skeletal defect present at birth. demonstrates * Assess the strength - This assessment 1. Patient
mother as manifested The syndrome measures to to perform ROM to provides data on demonstrates
by left leg often involves increase all joints. extent of any activity measures
Objective Data: mass. port wine stains, mobility. physical problems to increase mobility
- Left leg mass excess growth of and guides therapy. as manifested by
- Inability to move bones and soft 2. Patient is free Testing by a physical playing limited to
left leg tissue, and from therapist may be his ability.
- Limited varicose veins. complications of needed.
movements of the immobility, as 2. Patient is free
leg evidenced by * Assess input and - Pressure from complications
intact skin, output record and ulcers build up more of immobility as
absence of nutritional pattern. rapidly in patients manifested by
thrombophlebitis with a nutritional intact and absence
, normal bowel insufficiency. of skin breakdown,
pattern, and clear * Check for skin - Routine inspection absence of
breath sounds. integrity for signs of of the skin thrombophlebitis
redness and tissue (especially over and normal bowel.
ischemia (especially bony prominences)
over ears, shoulders, will allow for
elbows, sacrum, prevention or early
hips, heels, ankles, recognition and
and toes). treatment of pressure
ulcers.

*Establish measures - This is to prevent


to prevent skin skin breakdown, and
breakdown and the compression
thrombophlebitis devices promote
from prolonged increased venous
immobility: return to prevent
Clean, dry, and venous stasis and
moisturize skin as possible
necessary. thrombophlebitis in
Use anti embolic the legs.
stockings or
sequential
compression devices
if appropriate.
Use pressure-
relieving devices as
indicated (gel
mattress).

* Execute passive or - Exercise enhances


active assistive increased venous
ROM exercises to return, prevents
all extremities. stiffness, and
maintains muscle
strength and stamina.
It also avoids
contracture
deformation, which
can build up quickly
and could hinder
prosthesis usage.