Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Impaired physical Short Term: Independent: Expected outcome:

“Hindi ako pwede mobility related to Within 30mins of  Encourage to  To prevent The patient is
gumalaw, higa lang. musculoskeletal nursing intervention, participate in muscle expected to report
hindi pwede umupo,” impairment the patient tolerable ADLs atrophy and comfort and can
as verbalized by the secondary to spinal  can do ADLs bone perform ADLs as
patient. cord injury. as tolerated contractures mush as he can
 will have tolerate.
Objective: decreased pain  Identify energy-  To limit Goal met.
 Limited range or discomfort conserving fatigue and
of motion techniques for maximize
 Difficulty Long Term: ADLs participation
turning After 1 week of
nursing intervention,  Provide/secure  To reduce risk
the patient safety, raise side of falling, and
 Will not have rails further
pressure sores injuries
 Can perform
ADLs  Provide regular  To provide
independently skin care hygiene and
include
pressure area
management

 Encourage  To enhance
participation in self-concept
self-care and and sense of
diversional independence
activities

 Support affected  To prevent

body part bed sores and
decrease pain
or discomfort
  Encourage deep  To maximize
breathing lung
exercise expansion

 Encourage  To promote
increase intake well-being
of fluid and and maximize
nutritious food energy
production

Dependent:
 Administer  To relieve
medication, pain pain and
reliever discomfort
(Tramadol), as
ordered by the
physician.

 Assist with  To prevent

treatment of aggravation of
underlying the disease
condition
causing pain or
dysfunction.

Collaborative:
 Consult with  To develop
physical/occupat individual
ional therapist, exercise/mobi
as indicated lity program