Assessment Nursing

Diagnosis
Scientific
Rationale
Planning Intervention Rationale Evaluation
Subjective:
>Nangyari ito
nung nasa training
kami sa
mindanao, haang
nagagana! ang
aming training,
naaril ako sa
kali"ang inti# as
verali$ed
>#%ira! akong
maglakad dahil sa
nangyari sa akin#
as verali$ed
Objective:
>&se of crutches
>'alking on
limited distance
>(im!ing on
"alking
Diagnosis:
> Surgical site in
left leg )*endon
*ransfer+
Im!aired "alking
related to
neuromuscular
im!airment as
manifested y
lim!ing on "alking
,unshot 'ound
Skin and *issue
!erforation
Damaged veins,
ca!illaries, nerve
endings and
muscles
In-ury to fiula
one )(+
Surgical
intervention
)*endon
transfer+
&se of .rutches
Short Term:
>After /01 hours of
nursing
intervention he "ill
e ale to
verali$e
understanding of
situation or risk
factors and safety
measures
Long Term:
>After 2 month of
nursing
intervention he "ill
e ale to im!rove
his level of
"ellness and e
ack on his
normal routines
Dependent:
>Em!hasi$e the
condition or
diagnoses that
contriute difficulty
in "alking
>Em!hasi$e client
!articular
sym!toms related
to "alking
>Provide
assistance "hen
indicated
>Scheduled
"alking or
e3ercise activities
inters!ersed "4
ade5uate rest
!eriods
>Encourage active
and !assive
e3ercises
>Provide safety
measures
Collaborative:
>Refer to !hysical
thera!ist
>*o determine risk
factors and
enhance nursing
care !lan
>*o determine
s!eciali$ed care
!lan
>*o !romote
safety
>*o reduce fatigue
>*o increase
stamina and
endurance
>*o !romote
"ellness
>6or s!eciali$ed
management
>After the nursing
intervention has
een im!lemented
the client "ill e
ale to "alk
!ro!erly "ith the
use of "alking
materials
)crutches+
,7A(8
PAR*IA((9 :E*
Im!aired "alking

Independent:
>Administer
medications8
;.alcium
;< com!le3
;Protein
;=it> D
>for ones
>for nerves
>for muscles
>.alcium
asor!tion