Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur

College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BACKGROUND
Subjective: Impaired physical Cerebrovascular Short-term Independent Short-term Goal
“He had no mobility related to infarction Goal Establish rapport To gain trust Goal met. The
control of his Neuromuscular After 3 hours of and patient and s/o will
upper extremities impairment as nursing cooperation be able to
but there was evidenced by (+) Neuromuscular intervention, the understand the
limited movement left side body impairment patient and s/o Assist with To maximize situation and
in his lower” as weakness, limited will be able to treatment of the potential individual treatment
verbalized by the range of motion, understand the underlying for mobility regimen and safety
Tissue damage in condition causing
significant other postural instability, situation and and function measures and
the brain then pain
of patient decreased muscle brain cells begin individual demonstrate
strength/control treatment and/or dysfunction techniques/behavior
to die due to lack
and a verbalization of oxygen regimen and s that enable
of “He had no safety measures Advise the Reduces risk of resumption of
Objective: control of his and demonstrate significant other to tissue ischemia activities, after 3
 (+) left upper extremities techniques/beha change the position or injury hours of nursing
Pathways that
side body but there was transmits viors that enable of the patient every intervention
weakness limited movement information in the resumption of 2 hours, from
 Limited in his lower” by brain are activities supine to left or Long-term Goal
range of the significant interrupted right side-lying Goal met. The
motion other of the patient Long-term position patient will be able
 Postural Goal Instruct in use of For to maintain optimal
instability Weakness After 3 weeks of siderails, overhead changes, position of function
 Decreased nursing trapeze, roller pads, transfers, and as evidenced by (-)
walker, cane to facilitate
muscle intervention, the safe left side body
Impaired physical
strength/c patient will be ambulation weakness, normal
mobility
ontrol able to maintain range of motion,
Support affected
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur

College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

optimal position body parts or joints To maintain

stable posture,
of function as using pillows, rolls, position increased strength
evidenced by (-) foot of function and
and function of
left side body supports or shoes, reduce risk of
affected or
weakness, gel pads, foam, etc pressure ulcers
compensatory body
normal range of part, and a
motion, stable verbalization of
posture, “He was able to
increased Encourage control his upper
strength and adequate intake of Promotes and lower
function of fluids and well-being and extremities” by the
affected or nutritious foods maximizes significant other of
compensatory energy patient, after 3
body part, and a production weeks of nursing
verbalization of intervention
“He was able to Schedule activities
control his upper with adequate rest To promote
periods during the wellness and
and lower
day reduce fatigue
extremities” by
the significant
other of patient
Dependent
Administer
analgesic, To maintain
Acetaminophen “acceptable”
(Tylenol), as level of pain.
indicated. Notify
physician if
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur

College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

regimen is
inadequate to
meet pain
Collaborative: control goal.
Collaborate with
physical therapists
in providing range- To develop
of-motion individual
exercise (active or exercise and
passive), isotonic mobility
muscle program, to
contractions identify
(e.g., flexion of appropriate
ankles, push-and- mobility
pull exercises), devices, and to
assistive limit or reduce
devices, and effects and
activities (e.g., complications
early ambulation, of immobility.
transfers,
stairs)