ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATIO

DIAGNOSIS INTERVENTION N

1. Ensure patient’s 1. Most priority of a nurse is GOAL MET

safety. to provide safety.
SUBJECTIVE: Impaired SHORT 2. Evaluate and 2. Absence of pain SHORT
physical TERM. document reports of expression does not TERM.
“madalas na sumasakit ang mobility related pain or discomfort, necessarily mean lack of
itaas na bahagi ng aking likod” to loss of Within 2-4 noting location and pain. After 2-4 hours
as verbalized by the patient. integrity of bone hours of nursing characteristics, of nursing
structure as intervention the including intensity intervention the
evidenced by patient will be (0–10 scale), 3. Postural hypotension is a patient will be
severe pain in able to: relieving and common problem able to:
OBJECTIVE: upper back aggravating factors. following prolonged bed
rest and may require
 Diaphoresis specific interventions (tilt
3. Monitor Vital signs
 Facial Grimace >Report pain as table with gradual >Report pain as
 Irritability relieve or elevation to upright relieved or
4. Provide comfort controlled with
 Guarding behavior control with the position).
measure, quiet the pain scale
 Guarding and pain scale of 4. Helps to prevent joint
environment and of 4/10 from
tenderness are present 4/10 from 8/10 contractures and muscle
calm activities. 8/10
in cervical, thoracic, atrophy.
and lumbar spine. 5. Improves general
 Pain scale of 8/10 circulation; reduces areas
>Verbalize 5. Provide range of
motion exercises of local pressure and >Verbalized
understanding
every shift. muscle fatigue. understanding
Vital signs taken as follows: of condition.
Encourage active of condition.
range of motion
exercises.
BP-120/70 mmHg .
6. Refocuses attention, LONG
6. Provide alternative promotes sense of control,
T- 36.8 ° C comfort measures TERM:
and may enhance coping
(massage, backrub, abilities
PR-83 bpm position changes). After 1-2
7. Prevents musculoskeletal weeks of
7. Provide emotional deformities.
RR- 22 cpm LONG TERM: support and nursing
8. Preserves the patient’s intervention,
encourage use of muscle tone and helps
Within1-2 the patient was
stress management prevent complications of
weeks of able to
techniques. immobility.
nursing maintained
intervention, the functional
patient will 8. Apply trochanter mobility as
maintain rolls and/or pillows 9. Prevents complications of long as
functional to maintain joint immobility and possible within
mobility as long alignment. knowledge assists family limitations of
as possible 9. Assist patient with members to be better disease
within walking if at all prepared for home care. process.
limitations of possible, utilizing
disease process. sufficient help. A
one or two-person 10. Patient may be restricted
pivot transfer by self-view or self-
utilizing a transfer perception out of
belt can be used if proportion with actual
the patient has a physical limitations,
weight-bearing requiring information or
ability. interventions to promote
10. Instruct family progress toward wellness.
regarding ROM 11. To prevent further
exercises, methods complication.
of transferring 12. To assess client’s
patients from bed to knowledge.
wheelchair, and
turning at routine
intervals.

11. Assess the degree of

immobility
produced by injury
or treatment and
note patient’s
perception of
immobility.

12. Administer pain

reliever medication
as ordered by the
physician.
-Assess client
knowledge about
The causes,
treatment plan and
specific medication.