ASSESSMENT OBEJECTIVE DATA: y Limited ROM y Weakness at left and right upper extremities y Weakness at left and right

lower extremities y Bedridden

NURSING DIAGNOSIS Self-care deficit related to immobility secondary to generalized weakness

PLANNING Within the shift that patient will maintain proper hygiene as evidenced by: y Clean clothes y Absence of foul smell y Proper grooming

INTERVENTION Change the diaper of the patient Change the position of the patient every 2 hours Feed the patient through NGT Fix patient s clothes

RATIONLAE To prevent occurrence of rushes To prevent pressure ulcers

To meet nutritional needs To provide proper grooming. to provide proper grooming to clear airways to promote proper hygiene

EVALUATION The patient maintain proper hygiene as evidenced by: y Clean clothes y Absence of foul smell y Proper grooming

Provide oral care

Suction secretions Provide perineal care

Provide back massage to promote good circulation and relaxation