Name: Kenrick E.

Bajao

Year & Section: BSN-3E

An HIV positive 30 year old female on antiretroviral therapy (ART) was into tears and said “I cannot
move my right hand because it pains.” Other complaints presented to her HIV clinic were, with a two
week history of progressively worsening twitching and clumsiness in her right hand. The twitching had
become continuous making it difficult for her to use her hand. Her family also reported witnessing three
seizures over the last two weeks with loss of consciousness on each occasion.

Assessment

Subjective:

 Patient verbalized “I cannot move my right hand because it pains.”

Objective:

 Pain
 Twitching and clumsiness in the right hand

Diagnosis

Impaired physical mobility related to pain as evidence by reluctance to attempt movement.

Planning

General:

 After 3 days of nursing intervention the patient will be able to report pain relieved/controlled.

Specific:
 Increase strength and function of affected body part
 Patient demonstrates the use of appropriate diversional activities and relaxation skills.
 Patient will demonstrate the use of adaptive changes that promote ambulation and transferring.

Implementation

Independent:

 Assist with activity/progressive ambulation

Rationale: Until healing occurs, activity is limited and advanced slowly according to individual
tolerance.
Dependent:
 Administer analgesic medications as prescribe by the physician.
Rationale: To relieve mild or moderate pain.

Interdependent:

 Include intake nutritious of food and fluids.

Rationale: To recover quickly and promotes well-being. Good nutrition also gives required energy for
participating in an exercise or rehabilitative activities.

Evaluation

 Goal met. Patient able to relieved/controlled pain.