NURSING CARE PLAN

In Partial Fulfilment of the

Submitted to:
Johanna Zehender, RN
Clinical Instructor

Submitted by:
Kim Zascney O. Guiang, StN
BSN Year 2 Section I – Group 4

September 9, 2021
 NURSING CARE PLAN
Name of Patient: _________________________ Age: ___ Ward: Holy Child_______ Bed#:__
Chief Complaint: complaining of pains in her joints Diagnosis: __________________________ Physician: Dr.:____

Date Cues Need Nursing Diagnosis Patient Nursing Interventions Imple Evaluation
/ Outcome ment
Time ation
Sept. Subjective: Activity- Impaired Mobility related Within 8 A. Heat Therapy, deliver 1
9, -Pain in joints Exercise to Activity Intolerance, hours, the via moist hot packs
2021 -Joints mostly stiff in the decrease endurance, patient will: R: Deep or Superficial
8 am morning joint stiffness and pain as Heat application, is an
-Reported “tiredness” evidenced by swollen -Report effective way to relive Goal Partially
interphalangeal and relief of joint pain and stiffness, met
Objective: metacarpophalangeal pain it is also used to treat
-Skin is pale, clinically joints and tender joints in preparation for
anemic Hermetatarsophalangeal -Improve in ROM, stretching, and Goal Partially
-Lost 4kg in 4 months joints. range of muscle-strengthening met
-proximal interphalangeal motion exercises.
joints and R: Synovial cell
metacarpophalangeal hyperplasia and -Enhance B. Cold Therapy, deliver 2 Goal Partially
joints are swollen with endothelial cell activation strength via ice packs met
effusion progress to uncontrolled and R: Cold application to
-Tender inflammation and endurance treat an acutely
Hermetatarsophalangeal consequent cartilage and inflamed joint which also
joints bone destruction -Prevent or helps in decreasing pain Goal Partially
inflammation and Correct and muscle spasm. met
Laboratory Results: exuberant proliferation of deformities
-Low Hemoglobin the synovium (ie, C. ROM Exercises;
-High Urea pannus) leads to Flexion, Extension,
-High Creatinine destruction of various Rotation, Abduction, 3
tissues, including Adduction,
Medication: cartilage, bone, tendons, Circumduction,
-Diclofenac ligaments, and blood Supination, Pronation,
vessels. enlargement of Inversion, Eversion:
the synovial membrane (Lammon et al., 1995.)
 is noted on physical R: Exercise strengthens
examination as the muscles around the
thickening of the joints and helps
synovium that may lubricate the cartilage,
obscure joint margins. reducing swelling and
This thickening is most pain. Moving joints
evident in the small joints through the full range of
of the hands and feet. In motion improves
the MCP and MTP joints, flexibility and reduces
the outline of the base of stiffness, swelling, and
the proximal phalanx pain.
may become indistinct,
and in the PIP joints of D. 30-minute Aerobic
the fingers. Affected Exercise
joints show inflammation R: improves maximum 4
with swelling, oxygen intake and
tenderness, warmth, and decreases perceived
decreased range of exertion at submaximal
motion. Limitation of workloads, reportedly
motion occurs as a result without causing adverse
of articular surface effects in the joints
damage, joint and tendon
sheath swelling, or E. Joint- Protection
alteration of joint Education; maintenance
supporting structures. of good posture 5
(Smith, 2021) R: positioning yourself
correctly and using the
muscles best suited to a
task minimizes the
stress on your joints and
proper body mechanics
allow you to use your
body more efficiently.
References
Smith, H. R. (2021). Rheumatoid Arthritis (RA). Rheumatoid Arthritis (RA). Published.

https://emedicine.medscape.com/article/331715-overview

Herdman, T.H., & Kamitsuru, S. (2018) Nursing Diagnoses Definition and Classifications 2018-2020. 11th Edition. New York: Thieme

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