Assessment

Subjective:

Diagnosis
Impaired

Planning
Short Term:

Interventions
Independent:

Nahihirapan

physical

After 4 hrs of

- Establish

-To promote

akong lumipat

mobility related

nursing

rapport

cooperation

ng posisyon as

to discomfort

intervention,

verbalizedby

patient will be

the patient

able to

-Monitor vital

participate

signs

Rationale

-To have a
baseline data

Objective:

willingly on

-To prevent bed

-discomfort

necessary/desir

sores

-left leg swelling

ed activities.

-cant move

-Turn patient
every 2 hours

- Improving the

without

Long Term:

functional

assistance

After 1 day of

- Maintain

position of the

nursing

proper body

limb and

intervention,

position

prevent

patient will be

contractures.

able to
demonstrate a

- Reducing

decrease in

-Give the

muscle stiffness

physiologic

medicine before

and tension

signs of

the activity /

enables the

Evaluation
Goal was met.

intolerance

exercise.

patient to be
more active and
help
participation.

- Note the

-Edema can

circulation,

affect circulatio

movement and

n in the

sensation in the

extremities,

lower

which is the

extremities

potential for

often.

tissue necrosis.

-Assist patient

-To protect from

with activities

injury

-Plan care with

-To decrease

rest periods

fatigue & to

between

manage activity

activities and

within limits

increase activity
gradually

Assessment
Subjective:

Diagnosis
Activity

Planning
Short Term:

Interventions
Independent:

Rationale

--

intolerance

After 5 hrs of

- Establish

-To promote

Objective:

related to

nursing

rapport

cooperation

-body weakness

immobility

intervention,

-weak in

patient will be

-To help to

appearance

able to do ADLs

-Monitor vital

determine

-facial grimace

alone and

signs

patients

when moving

participate in

current health

-cannot perform

self-care

status

ADLs

activities.

-To protect from

Long Term:

-Assist patient

After 2 days of

with activities

nursing

injury
-To determine

intervention,

-Assess ability

patients

patient will be

to do ADLs

capacity

normal activity

-Assist in

-To maximize

level and a

performing

full strength

able to maintain

Evaluation
Goal was
partially met.

decrease in

range of motion

physiologic

exercises

signs of
intolerance