ASSESSMENT EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OF THE
PROBLEM
SUBJECTIVE: Limitation in STO: Dx: Dx: STO
“He can’t perform activities independent, Within 8 hours of GOAL MET:
without assistance” As purposeful physical consistent nursing  Assess the mobility  Allows the
verbalized by the SO. movement of the body interventions, the patient limitations of the implementation of
or of one or more will be able to: patient applicable methods
extremities. The  Verbalize related to mobility
environmental barrier understanding of
OBJECTIVE: of patients in the situation and
orthopedic ward where individual  To rule out
 Auscultate bowel
most cases have some treatment regimen constipation
 Decrease in range sounds. Monitor
kind of mechanical and safety
of motion elimination habits.
restriction such as cast, measures
 Difficulty in
splint, traction,  Maintain a
turning  Monitor blood
ventilator makes position of
 Musculoskeletal pressure and other  To maintain stable
mobility difficult. function
impairment vital parameters condition
 Attempt to
 Prescribed
Reference: exercise affected
movement
https://nandanursing extremity if not
restrictions
diagnoses.blogspot.co contraindicated
NURSING DIAGNOSIS:
m
/2012/07/nanda-self-  Assess the patient’s
Impaired physical mobility care-deficit.html willingness or ability
related to activity LTO:
Within 24-72 hours of to explore a range of  Cooperation from the
intolerance techniques aimed at
nursing interventions, the client and SO makes
patient will be able to: helping condition the care plan more
 Verbalize successful
knowledge of  Assess for other
healthcare complications related
practices to help to ward stay
current condition
 Demonstrate  Early detection allows
techniques and prompt response LTO
lifestyle changes GOAL MET:
to meet recovery
 Participate in Tx:
activities of daily
living  Acknowledge and
accept client’s
condition
Tx:
 Provide
 To establish trust
nonpharmacologic
pain management
such as DBE and
guided imagery.
 These methods are
used to provide
 Provide comfort by altering
pharmacologic pain psychological
management as responses to pain.
ordered.

 To alleviate pain. It is
preferable to provide
an analgesic before the
onset of pain or before
 Actively listen to it becomes severe
client’s concerns and when a larger dose may
the SO be required.

 Practice and promote