ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired Short Term  Monitor vital  To help Short term

“Hindi ko na Physical Objective : signsand record. determine Objective :
nagagawa Mobility After 6 hours  Monitor intake patients current Goal partially met
sir/ma’am yung related to of effective nursing andoutput as health status and because after 6
mga dati kong disturbed gait interventions, the order. evaluate hours of effective
ginagawa e” and center of patient will be able to  Assess ability to effectiveness of nursing
gravity of do ADL’s alone and perform ADL. nursing interventions, the
body. to participate in self-  Assess physical intervention patient is able to do
Objective: care activities. mobility status. rendered. ADL’s but with
 Weak in  Assist patient to  To evaluate the minimal assistance
appearance do ADL’s. proper and participate in
 Cannot  Assist to do functioning of self-care activities.
perform active range of his kidney in
ADL’s motion exercise relation to his
alone like flexing of present condition. Long Term
 Deviated Long Term Objective : both extremities.  To determine Objective :
thoraco- After 2 days of effective  Promote rest the capacity of Goal Fully met
lumbar nursing interventions, and comfort. patient in doing because after 2
spinal the patient will be able  Encourage to ADL’s. days of effective
column; to maintain activity verbalize  To know if there nursing
left- level within feelings and is any changes interventions, the
centered capabilities as concern on patient’s patient is able to
gait evidenced by normal regarding his condition maintain activity
 Muscle vital signs during present specifically on level within
strength: activity, as well as condition. physical aspect. capabilities as
Left upper absence of weakness,  Emphasize  To minimize evidenced by
extremity: pain, and difficulty importance of fatigue and to normal vital signs
4 accomplishing tasks. frequent evaluate his during activity, as
Right upper ambulation. capabilities in well as absence of
extremity=  Encourage doing such. weakness, pain,
4 active range of  To maximize and difficulty
Left lower motion full strength. accomplishing task
extremity= exercises like  To conserve s.
3 flexing of both energy.
Right lower extremities.
extremity=  Emphasize
3 importance
of compliance to
treatment and
medication.
 Encourage
adequate rest
periods