University of Pangasinan

PHINMA Education Network

College of Health Sciences

Patient’s Initials: E.B.DG Age & Gender: 78yrs old & F Chief Complaint: Name of Student Nurse: Abegail M. Quinto
Birthday: Admitting Diagnosis: Consider Stroke _ Level/block/group: Level 3/ Block 9
Address: Nagudgud Lingayen Pangasinan _ Hospital/area: JNGH/General Ward
Date of Confinement: 05/02/2023 _ Clinical Instructor: Ms. Jocelyn Macaraeg _ Date: 7/12/23

ASSESSMENT EXPLANATION OF THE PROBLEM PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Short Term Goals: Short Term Goals:
 After 8hrs of Dependent:  After 8hrs of
If the patient is diagnosed with
Patient is in ET and nursing  Provide emotional  Offer emotional support to nursing
unconscious Impaired physical mobility, refers intervention the support and education: the patient and their intervention the
patient will able family, addressing any patient was able
to a condition where an individual
to demonstrate fears, concerns, or to demonstrate
experiences limitations or techniques or psychological barriers techniques or
behaviors that related to impaired behaviors that
restrictions in their ability to move
Objective: enable mobility. enable
Vital Signs as follows: or engage in physical activities resumption of  Collaborate with  Communicate and resumption of
02 Sat- 99bpm activities. interdisciplinary team collaborate with physical activities.
due to various factors. It is a
BP-140/70 The patient will members: therapists, occupational  The patient was
RR-28 clinical term used to describe a demonstrate therapists, and other able to
HR-86bpm measures to healthcare professionals demonstrate the
patient's impaired or altered
T-37 increase mobility. to ensure coordinated use of adaptive
physical mobility, which may be  The patient will care and maximize devices to
General Appearance: demonstrates the mobility outcomes. increase mobility.
caused by musculoskeletal,
use of adaptive  The client
 Limited range of neuromuscular, cardiovascular, or devices to  Collaborate with the evaluates pain
motion increase mobility. healthcare team to and the quality of
respiratory conditions, as well as
 Decreased level  The client will  Assess the patient's pain develop a pain management.
of consciousness injury or disease processes. evaluates pain levels and address any management plan,  The client used
(GCS 6 and the quality of discomfort that may limit including pharmacological safety measures
E1V1M4) management. mobility. and non-pharmacological to minimize the
 Decreased This impairment can manifest as  The client uses interventions. potential for
cough reflex difficulty walking, performing daily safety measures injury.
 Inadequate self to minimize the
care activities, maintaining balance, or potential for
NURSING injury.
participating in functional tasks. It
DIAGNOSIS
 may involve decreased strength,
Impaired physical mobility
range of motion, coordination, or
related to paresis  Encourages relaxation
endurance, resulting in limitations
in mobility and functional
Long Term Goals:  Provide a calm
independence. o After environment; minimizing
24hrs the noise; limiting visitors and Long Term Goals:
patient length of stay. o After
Impaired physical mobility can will 24hrs the
significantly impact a person's performs patient
physical performed
quality of life, as it may affect their activity physical
ability to perform self-care independ activity
ently or independe
activities, participate in social within the ntly or
interactions, or engage in work or limits of within the
the limits of
recreational pursuits. disease. the
Rehabilitation, physical therapy, disease.
 After 2 days the
and assistive devices are often patient is free  After 2 days the
employed to manage and improve from patient was free
complications of from
physical mobility in individuals immobility, as complications of
with this condition. evidenced by immobility, as
intact skin, evidenced by
absence of intact skin,
thrombophlebitis, absence of
normal bowel thrombophlebitis,
pattern, and normal bowel
clear breath pattern, and clear
sounds. breath sounds.