Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired physical After 8 hours of  Assist patient  Adds to gaining After 8 hours of
mobility related to nursing for muscle enhanced sense nursing
“Hindi ko maigalaw ang
kaliwa kong kamay at
Musculoskeletal
intervention the exercises as of balance and intervention the
paa” as verbalized by the
impairment able or when strengthens
patient verbalizes patient was able
patient. allowed out of compensatory
understanding bed; execute body parts. to verbalize
Objective: situation or risk abdominal- understanding
factors and tightening situation or risk
 Limited range of exercises and
motion individual factors and
knee bends;
 Left hemi treatment regimen hop on foot; individual
paralysis and safety stand on toes. treatment regim
measures and safety
Establish measures to  This is to
prevent skin measures
prevent skin
breakdown and breakdown, and
thrombophlebitis the
from prolonged compression
immobility: devices
promote
 Clean, dry,
increased
and
venous return
moisturize
to prevent
 venous stasis
skin as and possible
necessary. thrombophlebit
 Use anti is in the legs.
embolic
stockings or
sequential
compressio
n devices if
appropriate.
 Use
pressure-
relieving
devices as
indicated
(gel
mattress).

 Exercise enhances
 Execute passive increased venous
or active assistive return, prevents
ROM exercises to stiffness, and
all extremities. maintains muscle
strength and
stamina. It also
avoids contracture
deformation,
which can build up
quickly and could
hinder prosthesis
usage.