Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective:
Impaired Physical After 4 hours of Monitor vital signs To obtain baseline Goal partially met.
“Masakit ang aking Mobility related to nursing and record them. data
katawan, kaya hindi pain as evidenced intervention,the After 4 hours of
ako masyado by difficulty in patient will no Provide a safe Raising side rails, nursing
makagalaw ng moving longer feel pain. environment. placing the bed in a intervention, the
maayos” as lower position, and patient's pain will
verbalized by the placing necessary reduce.
patient items nearby are
measures that can
Objective: help to prevent
falls.
Vital Signs:
Encourage the Assistive devices
BP: 130/90 appropriate use of promote
Temp: 36.7 assistive devices independence,
RR: 21 such as decrease pain, boost
PR: 63 wheelchairs, self-esteem, and
O2 Sat: 97% crutches, and canes. increase
confidence.
- Facial grimacing
- Difficulty in Administer To reduce pain
turning position medications as
ordered by the
physician.