PLANNING

NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Impaired Physical After 16 hours of  Inspect skin  Pressure points  Gently massaged the After 16 hours of
SUBJECTIVE Mobility related to nursing intervention, regularly, over bony reddened areas and nursing intervention,
DATA: paresthesia as the patient is expected particularly over prominences are provided aids such as the patient was able
“…Nasabi din po niya evidenced by to: to:
bony most at risk for sheepskin pads.
na nakakaramdam decreased muscle maintain optimal prominences. decreased  Placed a pillow Maintain optimal
daw po siya ng strength position of function perfusion between the legs of position of function as
pamamanhid sa braso
the patient and evidenced by the
at mukha" as
 Change position placing them in a absence of
verbalized by the  Frequently
frequently side-lying position contractures
patient’s significant changing the
afterwards.
other position of the
 Turned patient from
patient can
side to side as
OBJECTIVE DATA: reduce the risk
tolerated during the
 Right Side of tissue injury.
 Evaluate the day. Hip and knee in
Weakness
need for  To help aid and an extended position.
 Numbness of
positional aids provide extra  Assisted patient in an
the Face and
and splints support to upright position and
Arm
ADLs utilized an arm sling
 Unsteady Gait  Encourage
 Taught the patient to
active or ROM
use his unaffected
exercises
side to exercise his

 To improve affected side.

 Assisted the patient
 muscle strength perform ROM
and exercises.
maintenance of  Advised the patient’s
 Set goals with the patient’s significant other to
patient and range of motion maintain leg in
significant other and flexibility neutral position with
(SO) for a trochanter roll and
participation in to place a pillow
 Promotes a
activities and under the under the
sense of
position shoulder to abduct
expectation of
changes. the arm, keeping the
improvement
arm and hand
and provides
elevated.
some sense of
control and
independence.