Date Cues Need Nursing Objective of care Nursing Interventions Evaluation

& Diagnosis
Time
Nov.2 Subjective: C Impaired Physical Within 8 hours 1. Teach the patient to support all Goal met.
3, The patient O Mobility related span of nursing joints in a position of optimal After 8 hours of
2010 verbalized G to pain upon intervention my function: lie on a firm mattress. nursing
difficulty in N moving his right patient will be R: to assess functional ability. interventions, the
3 11 moving I leg. able to verbalize 2. Assess the degree of pain, client verbalize
because of T willingness to and listening to client’s description. willingness to and
his traction. I demonstrate R: to identify causative factors. demonstrate
V participation in 3. Encourage participation in self- participation in
Objective: E activities. care, occupational/ diversional/ activites; “try nako
V/S: - recreational activities. mag exercise sa
BP:120/80m P R: to enhances self- concept and sense of makaya nako” As
mHg E independence. verbalized by the
Temp: R 4. Encourage active range of motion patient.
36.8C C exercises.
PR:72bpm E R: to prevent joint stiffness.
RR:20cpm P 5. Understand that deformity does
-pain scale T not equate with disability and
of 7 out of U patient’s ability.
10 A R: to perform self- care.
L 6. Relieve persistent pain and
- facial morning stiffness to increase
mask P patients mobility and self-care.
- A 7. Provide assistive devices and
restlessness T assist the patient in learning to use
- guarding T them properly.
behavior E 8. Assist the patient when turning
- limited R side to side.
ROM. N 9. Provide skin care daily.
-difficulty in
turning side
to side.
-with
balance
skeletal
traction
attached.