ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data Impaired Physical

“Nahihirapan na ako Mobility related to Long Term Outcome Independent: > to be able to Partially Achieved
kumilos kasi hindi ko na musculoskeletal After 2 weeks of 1. Assist the client moved the
maigalaw yung kanang impairment as nursing intervention, to do the Range affected Long Term Outcome
part eng aking katawan” evidenced by slowed the client will be able of Motion extremities The client was able to
as verbalized by the movement to show increase in exercise with walk without
client strength and function assistance discomfort.
of affected body part 2. Schedule
Objective Data activities with >to reduce fatigue Short term Outcome
Short term Outcome adequate rest the client was able
 Stooped After 1 week of periods during to complete self-care
posture nursing intervention, the day activities.
 Staggering the client will be free 3. Provide safety
gait of complications like measures as
 Slowed changes in indicated by
involuntary individual
movement
movements of the situation,
body that might including
cause injury environmental
management/fall
prevention
Collaborative:
1. Administer
medications prior to >to permit maximal
activity as needed effort.involvement in
for pain relief activity
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Activity intolerance LONG TERM GOAL: Independent LONG TERM GOAL
 “Medyo related to presence  Rapport is WAS MET
nahihirapan po of surgical incision as After 2 days of  Establish important to gain
akong gumalaw manifested by limited nursing interventions rapport patient’s After 2 days of
dahil sa tahi ko” mobility on the lower the client will be able cooperation and nursing interventions
as verbalized by extremities to maintain activity reduce anxiety. the client exhibited a
the client level within normal range of
capabilities, as  Baseline data is respiratory pattern of
Objective data: evidenced by normal important to help 20 cpm, cardiac rate
heart rate during  Monitor vital determine of 79 bpm and has no
 Facial grimace activity, as well as signs shortness of breath
patient’s current
when moved absence of shortness and fatigue during
health status and
 VS: of breath, weakness, any activity.
evaluate
o T: and fatigue.
effiectiveness of
36.6 °C nursing
o P: 62 intervention
bpm rendered.
o R: 20  Establish
cpm guidelines and  Motivation is
o BP: goals of activity enhanced if the
110/80 with the patient patient
mmHg and caregiver. participates in
goal setting.
 Pain scale of 8  Encourage
out of 10 adequate rest  Rest between
periods, activities
 Burning
especially provides time for
sensation on
before meals, energy
incision site
other ADLs, conservation and
exercise recovery.
 Guarded
sessions, and
movement
 ambulation.
 Limited  Acknowledgmen
mobility on lower  Encourage t that living with
extremities verbalization of activity
feelings intolerance is
regarding both physically
limitations and emotionally
difficult, aids
coping.

 Promotes rest
and sleep and
 Maintain a prevents anxiety
quiet, thereby
comfortable decreasing the
environment patient’s oxygen
demands

 This promotes
awareness of
when to reduce
 Teach activity.
patient/caregiver
s to recognize
signs of physical To conserve energy
over activity. and decrease the need
for oxygen supply
Teach energy
conservation
techniques.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: Within 2 to 3  Identify factors that affect To know the After 2 to 3 hours
O: Risk for Falls hours of safety needs. intervention that will be of rendering proper
>decreased related to rendering established. nursing
strength in lower fatigue. proper nursing  Assess the patient ability intervention, the
extremities intervention, the to ambulate safely with or It is helpful to determine patient will be free
>weak in patient will be without assistive devices. the client’s functional from fall as
appearance free from fall. abilities to plan for evidenced by ability
>absence of side ways of improving the to explain the safety
rails  Thoroughly orient the problem areas precautions.
>presence of patient to environment.
scattered rugs For the client to
 Assess vision and provide familiarize the
Nursing adequate lighting to surroundings.
Diagnosis: clearly see the pathway.
Risk for Falls r/t  Ask the significant others To provide well-lighted
body weakness to always stay with the environment and avoid
client. the occurrence of
Scientific injury.
Explanation:  Instruct the patient to call To ensure clients safety.
Increased for assistance when
susceptibility to moving.
falling that may To prevent the patient
cause physical  Put side rails. from falling on bed.
harm.
 Provide assistive devices To reduce the risk of
for walking such as cane, falling.
crutches and/o
wheelchairs. For the clients support.

 Ensure that the patient

wears proper shoes
To prevent from
slippering.
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired Gas Discharge Independent: Discharge

Exchange related Outcome: Outcome
“Mabilis ang to altered oxygen ACHIEVED:
kanyang paghinga” supply (obstruction After 3 days of
as stated. nursing -Monitor skin and -Duskiness and After 3 days of
of airways by
intervention the mucous membrane central cyanosis nursing intervention
secretion) as
client: color indicate advanced the client:
evidenced by hypoxemia
Objective: wheezes upon -Manifest absence -Manifested
auscultation of wheezes upon absence of
-RR: 28 cpm
auscultation wheezes upon
-Oxygen delivery
-PR: 102 bpm -Elevate head of the auscultation
-Attain normal may be improved
bed, assist patient to by upright
-wheezes upon breathing pattern - Attained normal
assume position to suctioning
auscultation of 20 cpm breathing pattern of
ease work of breathing
20 cpm
-with pulse
oxymeter
-Suction when needed
-with mechanical -Suctioning is
ventilator required when
cough is ineffective
for expectoration of Short-term
Short-term secretions outcome
outcome: ACHIEVED:
After 2 hours After 2 hours
of nursing -Presence of of nursing
intervention the wheezes may intervention the
client: -Auscultate breath indicate
sounds, noting areas of
-Demonstrate decreased air-flow or bronchospasm/ client:
improved presence of retained secretions
ventilation and adventitious sound -Demonstrated
adequate improved
oxygenation of ventilation and
tissues by ABG of: adequate
pH:7.35-7.45 oxygenation of
-Decrease of
tissues by ABG of:
-Palpate for fremitus vibratory tremors
paCO2: 35- pH:7.35-7.45
suggest fluid
45mmHg collection or air paCO2: 35-
paO2: 80-95mmHg tapping 45mmHg

-Decrease paO2: 80-95mmHg

respiratory rate -External stimuli -decreased
from 28cpm to 13 may prevent respiratory rate
cpm relaxation or inhibit from 28cpm to 13
sleep cpm
-Provide quiet
environment to allow
the patient to relax

-to identify if
Collaborative: hypoxia is present

-Monitor pulse oximetry -to reduce dyspnea

and ABGs by controlling the
anxiety and
restlessness
-Administer antianxiety,
sedative, or narcotic
agents as -use as aid in
indicated(e.g.morhine) treatment

-Hooked to mechanical
ventilator Reference:

Nursing care Plan

by Marilyn
Doenges, 7th edition
p.124-125
ASSSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data Activity Intolerance Long Term Outcome Independent: Partially Achieved
“Nahihirapan na ako related to immobility After 2 weeks of 1. Ascertain > to determine
kumilos kasi hindi ko na as evidence by nursing intervention, ability to stand current status and Long Term Outcome
maigalaw yung kanang paralyzed right the client will be able and move needs associated The client was able to
part eng aking katawan” extremities. to walk without about and with participation walk without
as verbalized by the discomfort. degree of in needed/desired discomfort.
client assistance activities
Short term Outcome necessary use Short term Outcome
Objective Data After 3 days of nursing of equipments. the client was able to
intervention, the client 2. Provide >helps to minimize complete self-care
 Edema on the will be able to positive frustration and activities.
right foot >participate willingly in atmosphere rechannel energy
 Immobility of necessary or desired while
the right activities acknowledging
extremities >able to complete self- difficulty of the
care activities situation for
 Discomfort
the client. >to protect client
3. Assist with from injury
activities and
provide/monit
or client’s use
of assistive
devices >to develop
Collaborative: individually
1. Provide referral appropriate
to other disciplines, therapeutic regimens
such as exercise
physiologist,
psychological
counseling,
occupational/ physical
therapist s and
recreation/ leisure
specialists as indicated