NURSING NURSING

ASSESSMENT PLANNING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: Short Term: Independent: Short Term:
“Hirap nga ako Within 2-4 > Identify the condition/ >to assess the patient’s ability After 2-4 hours of
maglakad” as Impaired hours of diagnoses that contribute to to walk and to prevent further adequate nursing
verbalized by physical adequate difficulty walking(pain, acute injury intervention the
the client mobility r/t nursing illness) patient was able
decreased intervention the >Note emotional/ behavioral >feeling of frustration/ to determine risk
muscle patient will be responses to problems of powerlessness may impede factors and safety
strength able to immobility attainment of goals. measures
Objective: secondary to determine/ >support affected body >to maintain position of >Goal met
>difficulty pain understand parts/ joints using pillow function and reduce risk of
walking situation/ risk pressure ulcers
>gait factors and >Encourage participation in >to enhance self-concept and
changes( decre safety self-care and diversional sense of independence Long Term:
ased walking measures activities After the shift of
speed) Long Term: >provide for safety >to prevent further injury adequate nursing
>movement measures intervention the
induced SOB/ Within the shift patient wasn’t
of adequate Dependent: able to mobilize
tremor
nursing >Administer drug as >to relief pain and to promote but was able to
>functional
intervention the prescribed maximal effort/involvement in maintain or
level of 0
(completely patient will be activity increase strength
independent) able to and function of
Collaborative:
maintain or affected area by
>Promote adequate fluid >promotes well- being and
increase lifting the legs.
and high caloric diet maximizes energy production
strength and >Goal partially
>Consult/refer to a physical
function of met
therapist >to develop individual
affected area
exercise/ mobility and identify
appropriate adjunctive devise