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NAME: Stephen S. Padayhag CLINICAL INSTRUCTOR: Hiawatha A.

Pangarungan LEVEL: BSN – 3 Assessment Subjective Cues: Father verbalizes “ Dili ni maka tindog si welgie kay inig mu aksyon syag hawa sa katre unya mu kali tog abot ang tuyok, mag kapuluke cya og kaput kay malipong man siya…” Mother Verbalizes “…mag patabang ka og hawid nak? Pag saba lang.” –stating that patient W might need assistance ambulating from CR to Bed. Patient Verbalizes “Pasensya na kayo, ako lang jud tabunan ako mata kay mag lipong lipong ko.” Objective Cues: • • • • • • • Patient and watchers report trouble when ambulating. Patient report weakness and nausea when dizziness attacks. Limited movement when ambulating. Limited ability to perform basic needs. Difficulty during ambulation. Slowed movement and decreased reaction time. Patient shows signs of resignation (asks her mother for a glass of water given directly to her grasp.) Patient places a night shade over her eyes and ear plugs on her ears. Diagnosis

DATE: August 23, 2010 AREA: STATION 4-C SHIFT: 7am – 3pm Planning Short Term: after an hour or so…  Verbalize of understanding of situation/risk factors and importance of treatment rendered, and safety measures. Demonstrate techniques that are alternative but helpful to ambulation. Arranged room to her suit her needs. Encouraged patient to use emergency safety precautions.  Intervention Assist client to learn safety measures: Evaluation Goals partially met:  Patient understood the importance of using hands to grasp for support to the wall.  Patient has demonstrated this ( as stated above)  Removed objects that comes in her way to the CR, • • Patient is unwilling to perform beyond demonstration. Patient verbalizes “Ikatulog ko nalang ni, hago hago lang na.”

Impaired physical mobility as evidenced by dizziness and general weakness related to sensoriperceptual impairment, reluctant to initiate movement and environmental stimuli.

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Long Term: After 8 hours…   Adjust and cope well with new temporary lifestyle. Ambulate in a small distance of 5-8 meters without assistance from CR to Bed.

Use of hands to absorb fall. o Use of hands to grab nearby firmly attached objects. o Use of hands to reach outward to provide balance and quick support on wall. o Ask for support from watcher.  Involve client/ watcher in care assisting them to learn ways of managing problems of immobility.  Moved objects that will be on her way when walking to the CR.