ASSESSMENT NURSING DIAGNOSIS
Subjective:
“Nakakaramdam naman ako
pero ung kaliwang part ng
katawan ko walang laban.”
Objective:
 Pale palpebral
conjunctiva
 Pale nail beds with
capillary refill time,
<3sec.
 Able to feel deep touch
 Cannot move left arm
and leg
 Left sided weakness
 Slowed movement
 Slurred speech
 (-) DOB
 (-) chest pain
INFERENCE GOAL INTERVENTIONS RATIONALE EXPECTED OUTCOME
Impaired physical The nervous system is Short Term Independent Short Term Objective:
mobility related to made up of nerve cells Objective: >Establish Rapport > To gain pt’s Fully met.
neuromuscular and called neurons that serve After 8 hours of therapeutic After 8 hrs. of Nursing
musculoskeletal as the communication nursing relationship Intervention, the pt.
impairment secondary system of the body. They interventions, the >Assess patient >To determine any shall be able to
to limited motor skill carry messages in the patient will be able condition other underlying maintain increased
form of electrical impulses. to maintain cause of strength and function of
The messages move from increased strength manifestations affected or
one neuron to another to and function of >Provide adequate > To prevent further compensatory part.
Reference: keep the body functioning. affected or rest periods as well stress & fatigue
Because neurons have, compensatory part as comfort & safety
Doenges, M. Moorhouse,
M.F. Murr, A. (2008). limited ability to repair as evidence by: measures
Nurse’s pocket guide: themselves unlike other >Turn pt. slowly > To provide proper
Diagnosis, prioritized
interventions, and body tissues that is why from side to side circulation of blood
rationales. (11th ed.). nerve cells cannot be flow on both sides
Philadelphia,
repaired if damaged due to >Determine pt. level >To assess
Pennsylvania. E.A.
Davies Company. 457-61 injury or disease. of mobility functional ability
>Assist pt. in his >To promote optimal
activities level of function
>Promotes well-being
 Functional Level >Encourage and maximizes
Classification=2 adequate intake of energy production.
fluids & Nutritious
foods >To develop
Collaborative individual mobility
>Consult physical program and identify
therapies appropriate mobility
devices.

Reference:

Doenges, M.
Moorhouse, M.F. Murr,
A. (2008). Nurse’s
pocket guide:
Diagnosis, prioritized
interventions, and
rationales. (11th ed.).
Philadelphia,
Pennsylvania. E.A.
Davies Company. 457-
61