Name: Baile,Corazon y Bsn 3-E Malolos physical therapy and rehabilitation center Mr.

jonh paul Mendoza R,N Assessment Subjective data:  Nahihirpan akong kumilos. As verbalized by the patient. Nursing Diagnosis Scientific Knowledge Vehicular accident Planning

name of patient: Cristina Garcia Diagnosis: Motor Vehicular Accident

Implementation Dependent:  Instruct the patient to use assistive device like siderails or wheelchair.  Support affected body parts or joint using pillow, rolls, t support.  Provide for safety measure as indicated by individual situation including environmenta l management and full prevention.  Provide

Rationale

Evaluation

Impaired physical mobility r/t musculoskelet al impairment as evidenced by decrease Objective data: muscle  Slowed movement of strength. both upper and lower extremities.  Difficulty turning  Limited range of motion of both upper and lower extremities.

Short term goal: In 2-3 hours of nursing interventions the client Injuries of will be able to maintain face and or increase strength extremities and function of affected body parts as evidenced Inflammatio by: n 1. Verbalize understanding Impaired of situation and physical individualtreat movement. ment regimen and safety measures. 2. Ability to move the affected body parts without discomfort. 3. Demonstrate technique or behaviors that enable

After 2-3 hours of For position nursing changes or interventiongoals transfer. to maintainor increase strength and function of affected body To maintain parts were met as position function evidenced by: and reduced risk 1. Ability to of pressure ulcer. move the affected body parts To prevent the without patient from discomfort injury. 2. Verbalized understan ding the situation and individual treatment regimen and safety To maintain the measure

resumption of regular skin activities. care to include Long term goal: pressure area After 2-3 weeks of management. nursing intervention the  Encouraged patient will be able to the patient improve physical adequate mobility as evidenced intake of by: fluids and  Ability to nutritious performed food. ROM exercise.  Encouraged  Participate the patient to ADLs and have regular desired exercise. activity.  Ssscheduled  Maintain activities with position of adequate rest function and period during skin integrity the day. as evidenced by absence of Independent:  Assist contracture, or footdrop, have decubitus. the  Ability to walk patien the patient t without reposi assistive tion device. self on a regula r

patient integrity.

To promote well being and maximized energy production.

Demonstrate technique or behaviors that enable resumption of activities.

3. Ability to performed ROM exercise.

To promote proper circulation of blood in the body. To reduce fatiue.

To promote the patient progress.

sched uled as dictat ed by individ ual.  Perfor med ROM exerci se as doctor s ordere d.  Perfor med warm compr ess as doctor s odere d.

To promote patient muscle strength

To promote healing process.