ASSESSMENT NURSING RATIONALE EXPECTED NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OUTCOME
SUBJECTIVE: Impaired Motor vehicle After 8 hours of  Assess the degree of pain,  To determine The patient was
“Dae ako physical accidents (leading nursing listening to client’s whether the degree able to maintain
cause of head
masyadong mobility r/t intervention the perception. of pain changes. skin integrity as
injuries)
nakakahiro ta pain or patient will be  Assess nutritional status  Promotes wellbeing evidence by
pag naghihiro discomfort able to: and client’s report of and maximizes energy absence of
ako grabe ang Sudden impact  Verbalize energy level. production. contractures,
kulog kang payo force to the head understanding  Determine the degree of  To assess functional footdrop,
ko” as or inertial forces of situation immobility in relation to ability. decubitus.
within the skull
verbalized by and individual previously suggested scale. with Pain scale:4
the patient. treatment  Observe movement when  To note any and can cooperate
OBJECTIVE: Depressed skull regimen and client is unaware of incongruencies with more with the
 Body fractures, injure safety observations. report of abilities. nurse
weakness the brain by measures
 Irritable bruising it with  Maintain skin  note emotional/behavioral  Feelings of
possible surface
doest want integrity as responses to problems of frustration/powerless
hemorrhage.
to be evidenced by immobility. ness may empede
touched absence of attachment of goals.
 Pain scale Cerebral contractures,  Assist/have client  To prevent formation
8/10 contusion foot drop & reposition self on a regular of pressure ulcers.
V/S Contusions cause decubitus. schedule as dictated by
swelling and pain
 BP: 110/70  Participate in individual situation
and limit joint
mmHg range of motion ADL”S and  Provide regular skin care to  To prevent formation
 PR: 84 bpm near the injury. desired act. include pressure area of pressure ulcers.
 RR: 24 cpm Torn blood management.
 Temp: 37 °C vessels may  Identify energy conserving  So that patient can
cause bluish techniques for ADL’s. perform without
discoloration. The
losing too much
injured muscle
may feel weak and energy.
stiff.  Provide safety measures  To provide safety.
 Encourage SO involvement  Enhances
in decision making as much commitment to plan,
as possible. optimizing outcome.