ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Impaired Limitation of After 2 days of nursing  Assess for  Identifying After 2 days of nursing
“hindi po physical independent, intervention, the impediments the specific intervention, the
magalaw ang mobility purposeful patient will be able to: to mobility cause guides patient was able:
katawan.” As related to physical - Maintain design of - to maintain
verbalized by immobilization movement of position of optimal position of
significant others by traction the body or function and treatment function and
one or more skin integrity plan skin integrity
extremities. as evidenced  Inspect for  Patient is at as evidenced
Objective Data: by absence of localized risk for by absence of
- Limited contractures, tenderness, development contractures,
range of foot drop and redness, of deep vein foot drop and
motion decubitus. skin, thrombosis decubitus
- Upper - Verbalize warmth, and - the patient
body understandin muscle pulmonary and significant
weakness g of situation tension, embolus others was
noted and safety muscle able to
- Skull measure, tension. verbalize
traction Observe for understandin
noted sudden g of situation
dyspnea, and safety
tachypnea, measures.
fever,
respiratory
distress and
chest pain
 Promote  To assure
safety and protection of
security by client from
raising side injury and fall
rails and
assisting
when
ambulating
 Determine
presence of  To prevent
complication from any
related to worse case
mobility
 Use padding
and  To prevent
positioning stress on
devices tissue and
reduce
potentials for
disuse
 Support complications
affected  To maintain
body position of
parts/joints function and
using reduce risk of
pillows, rolls, pressure
foot support, ulcers
and gel pads
 Encourage
and facilitate  The longer
early the patient
ambulation remains
and other immobilize
ADLs when the greater
possible the level of
debilitation
that will
occur.