Assessment Nursing Diagnosis
Independent:
Objective  Physical immobility related
Observation:
 Headache
 Nausea and
vomiting  (Weber & Kelly
 Weakness of the left
side of the body,
numbness and
tingling sensation.
Subjective:
The patient verbalized that
“sumasakit ang ulo ko on
and off sya minsan wala
minsan meron at madali
akong mapagod at
nagsusuka rin ako
Independent:
to physical deconditioning
as evidenced by weakness,
numbness and tingling
sensation.
Planning
SHORT TERM GOAL:
After 1 hour of nursing
intervention the client:
 Is willing to participate
in activities.
 Maintain normal
vital signs.
 Reports decreased
severity or elimination
of nausea
LONG TERM GOAL:
After 3 hour of nursing
intervention the client:
 Understand the
disease and the
importance of the
diagnosis and
treatment.(health
teaching)
 Will be able to
improve and increase
strength and function
of the body
Intervention Rationale Evaluation
SHORT TERM GOAL:
1. Establish rapport  Client involvement After 1 hour of nursing
with the patient in decision making is intervention the client:
an integral part of
care delivery  Participate in the
prescribed activities.
2018, Health  Normal vital sign has
Assessment in been maintained.
Nursing 6th  Elimination of nausea
edition) decreased.
Signs of activity intolerance LONG TERM GOAL:
2. Assess client and decreased tissue After 3 hour of nursing
intervention the client:
developmental level, oxygenation include
motor skills ease and dyspnea on exertion,
capability of headaches, dizziness,  . The patients
movement and understand the
palpitations, and
importance of the
posture. verbalization of increased treatment to her
exertion level. disease, participate to
(Fundamentals of Nursing, the health teaching.
7th Edition. Pg1058  Improve and increase
strength and function
3. Assess emotional  Depression over the
of the body.
response to inability to perform
limitations in activities can be a
physical activity. source of stress and
frustration.
(Fundamentals of
Nursing, 7th
Edition. Pg1012)
4. Maintain a  Balance between rest
comfortable or sleep and exercise
environment to is essential to
promote rest rejuvenating body.
(Potter and Perry
2005,
Fundamentals of
MCALIM2020
 Nursing)

5. Provide safety by  Weakness, fatigue

raising side rails
and restlessness are
signs if hypoxia
which may cause
injury to the patient.
Fundamentals of
Nursing (Concepts,
Process and
Practice) 7th
Edition pg. 583

6. Provide an emesis Nausea and vomiting

basin within easy
reach of the patient.
are closely related.
Keep emesis basin
out of sight but
within the patient’s
reach if nausea has a
psychogenic
component.
Fundamentals of
Nursing 7th Edition
pg. 135


Dependent

7. Administer Dependent
medication as
indicated:  Medication
adherence is
important for
controlling chronic
conditions, treating
temporary
conditions, and
overall long-term
health and well-
being.

MCALIM2020
 (Fundamental of
Nursing 7th Edition
pg. 786)

COLLABORATIVE: COLLABORATIVE:
8. . Coordinate with a
physical therapist,  Consultants may be
also with med tech helpful in ensuring
for laboratory that proper
findings treatments are met.
Fedorovich C;
Littleton MT. Chest
physiotherapy:
Evaluating the
effectiveness.
Dimensions of
Critical Care
Nursing

MCALIM2020