Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired physical Short term Goal: >Establish rapport > To gain the patient trust and >goal was met.
“hindi ako mobility related to >Within the shift the cooperation during the entire
maxadong decreased strength patient will have a much procedure.
makagalaw and endurance. more wider range of
nanghihina ako” as motion than before and >Reviewed functional >Identifies probable functional
verbalized by the slight increase in abilities and reasons for impairments and influences
patient endurance impairment. choice of intervention.

Objective: Long term Goal: >Provided assistance for >Maintains mobility and
>the patient is weak >After 4 days of nursing range of motion exercise. functions of joints alignment
>the patient has intervention the patient of extremities and reduces
limited range of will achieve full venous stasis.
movements restoration of ROM,
>minimized strength and endurance. >Kept necessary utensils >Keeping all in reach, can
movements within reach of the patient. greatly reduce the risk of
>stays in bed most accident to the patient.
of the time
>Encouraged patient to do >This is to enable the patient
self care activities such as to regain muscle strength and
oral care, walking exercise. keeping himself clean, and
will gain independence.