Kelly Vergel de Dios

BNS3A

ASSESSM NURSING SCIENTIFI PLANNING INTERVENTION SCIENTIFIC EVALUATION

ENT DIAGNOSIS C
EXPLANA (IMPLEMENTAT RATIONALE
TION ION)

Subjective Impaired
Cues: Physical Impaired Short term Independent Independent NI: Short Term Goal:
Mobility physical Goal: NI:
mobility is After 30 mins of
defined as After 30 mins of 1. Obtain 1. To Provide nursing intervention,
Objective a limitation nursing Vital baseline the client will have a
Cues: in intervention, the signs of information better understanding
independen client will have a the 2. To provide of his present
t and better patient comfort situation and the sort
purposeful understanding of 2. Assist in position of therapy he will
physical his present reposition 3. To provide undergo.
movement situation and the ing wound
of the body sort of therapy his/hersel hygiene (GOAL MET)
or one or he will undergo. f 4. To prevent
more 3. Performe muscle Long-Term Goal:
extremities. Long-term wound stiffness by
Goal: care After 6hrs of nursing
stretching or
Impaired 4. Instruct to intervention, The
moving his
physical After 6hrs of use rail client will be able to
upper or
mobility can nursing and perform his daily
lower
be a result intervention, The headover living activity and
extremities
of disease client will be able trapeze move his right
5. To prevent
or during to perform his 5. Encourag affected in a leg
from muscle
rehabilitatio daily living e to atrophy and slowly manner.
n process. activity and move performe dysfunction
For his right affected d ROM of leg area (GOAL MET)
example, in a leg slowly exercise 6. To prevent
trauma, manner. 6. Encourag constipation
multiple e to and
sclerosis, increase dehydration
morbid consumpt 7. To prevent
obesity, ion of pneumonia
stroke, foods that
fracture etc are high Dependent NI:
in fiber
and 1. To treat and
increase prevent
in water certain
fluids infections
7. Instruct to
do deep
breathing
and
coughing Collaborative NI:
exercise
1. To promote
Dependent NI: the
enhanceme
1. Administe nt of the
r intervention
cefuroxim to the
e as patient’s
prescribe right
d by the affected leg.
physician
Collaborative
NI:

1. Refer to
physical
therapist