ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Bedridden Impaired Short term: 1. Assess functional 1. Identifies Goal Met:
physical After 8 hours of ability. strength or
Subjective: mobility related nursing deficiencies and After 8 hours of
“Not applicable” to impaired skin intervention, may provide nursing
interventions, the
integrity. patient will information
patient demonstrate
Objective: increase muscle regarding recovery increase muscle
- powerlessness strength and can and assists in strength and can
- prolonged bed rest perform body choice of perform body
- decrease muscle movements such interventions. movements such as
strength as raising her raising her hands
- limited body hands slowly. 2. Turn and 2. Regular turning slowly.
movements position patient promotes
- stiffness every three (3) circulation to all
- weakness hours. tissues and relieves
pressure.

3. Provide good 3. Reduces risk for

skin care and gently decreased perfusion
massage pressure and ischemia to
points after each prevent skin
position change. irritation or
breakdown.

4. Perform active 4. Maintains

and passive ROM mobility and
function of joints,
functional
alignment of
 extremities,
minimizes muscles
atrophy, promotes
circulation and
reduces venous
stasis.

5. Inspect for 5. Patient is at risk

localized for development of
tenderness, redness deep vein
and ropy veins in thrombosis (DVT)
calves of legs. and can cause
pulmonary
embolism,
requiring prompt
intervention to
prevent serious
complications.
 ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Constipation Constipation Short term: 1. Assess usual pattern 1. Normal Short term: Short term:
related to After 3-5 hours of elimination; frequency of After 3-5
Subjective: decreased of nursing compare with present passing stool hours of Goal Not Met
“Not applicable” physical activity interventions, pattern. Include size, varies from twice nursing
or immobility. the patient will frequency, color, and daily to once interventions, After 3-5 hours of
Objective: defecate. quality. every third or the patient nursing intervention
- not defecating fourth day. It is will the patient didn’t
within 2 to 3 days Long term: important to demonstrate defecate.
- distended After 2-3 days ascertain what is improved
abdomen of nursing normal for each bowel
- constipated date: intervention individual. function. Long term:
17-11-19 patient will (Gulanick, p.43)
18-11-19 defecate Long term: Goal Met
19-11-19 (AM normally 2. Check for 2. Further After 2-3 days
Shift; 0930H- impaction if patient interventions/alter of nursing After 2 days of
2130H) has not had bowel native bowel care intervention nursing
movement in 3 days may be needed. patient will interventions, the
or is abdominal (Doenges, p. 829). demonstrate patient defecates
distortion, cramping. normal with the help of
defection laxative (Movicol).
3. Administer 3. Softens stools, without using
laxatives, stool promotes normal laxative.
softeners as indicated habits and
(e.g. Movicol). decreases
straining.
(Doenges, p. 267).