ASSESS NURSING PLANNIN NURSING RATIONA EVALUAT

MENT DIAGNOS G INTERVE LE ION

IS NTION
SUBJECTIV Impaired SHORT SHORT
E DATA: physical TERM: 1. Assess the 1.Maintaining TERM:
mobility patient functional
"The pain is related to After 8 hours functional mobility as After 8 hours
loss of of nursing agility for long as of nursing
becoming
integrity of intervention mobility and possible intervention
worse, and bone the patient note within the patient
it is keeping structure as will verbalize: changes. limitations of improved as
me from evidenced by disease manifested
doing my severe back ● decre 2. Monitor process. by:
daily pain with the ase blood
activities” as scale of 8/10 the pressure 2. Postural ● decre
verbalized pain (BP) with the Hypotension ase
by the from resumption of is a common the
patient the activity. Note problem pain
8/10 reports of following from
to the dizziness. prolonged the
OBJECTIV
4/10 bed rest and 8/10
E DATA: ● under 3. Provide a may require to the
stand range of specific 4/10
● Guar the motion interventions. ● under
ding risk exercises stand
beha factor every shift. 3. Helps to the
vior s of Encourage prevent joint risk
● Pain the active range contractures factor
scale individ of motion and muscle s of
8/10 ual exercises. atrophy. the
● Tend treatm individ
ents 4. Apply 4. Prevents ual
ernes
● under trochanter musculoskele treatm
s are stand rolls and/or tal ents
prese the pillows to deformities. ● under
nt in situati maintain joint stand
cervic on of alignment. 5. Preserves the
al, havin the patient's situati
thora ga 5. Assist muscle tone on of
cic, regim patient with and helps havin
and en walking if at prevent ga
lumb and all possible, complications regim
ar safety utilizing of immobility. en
meas sufficient and
spine
ures help. A one 6. Prevents safety
. or two-person complications meas
● Limit LONG pivot transfer of immobility ures
ation TERM: utilizing a and
of transfer belt knowledge LONG
move After 2 weeks can be used assists family TERM:
ment of nursing if the patient members to
intervention, has a be better After 2 weeks
at
the patient weight-bearin prepared for of nursing
cervic will be: g ability. home care. intervention,
al the patient
spine ● maint 6. Instruct 7. Patient has able to:
area ain family may be
functi regarding restricted in ● maint
onal ROM self-view or ain
mobili exercises, self-perceptio functi
ty as methods of n out of onal
long transferring proportion mobili
as patients from with actual ty as
possi bed to physical long
ble wheelchair, limitations, as
within and turning at requiring possi
limitati routine information or ble
ons of intervals. interventions within
disea to promote limitati
se 7. Assess the progress ons of
proce degree of toward disea
ss immobility wellness. se
produced by proce
injury or 8. To prevent ss
treatment further
and note the complication.
patient's
perception of
immobility.

8. Administer
medication
as ordered by
the physician.