Assessment

Objective:
(+) limited range
of motion
(+) slowed
movement
(+) postural
instability

Diagnosis

Planning

Peptic Ulcer :
Impaired physical
mobility related to
pain

After 4 hours of
nursing
intervention the
client will be able
to :
-Verbalize
understanding of
situation and
individual
treatment regimen
and safety
measures.

-Demonstrate
techniques or
behaviors that
enable
resumption of
activities.

-Participate in
ADLs and desired
activities.

Nursing
Intervention

Rationale

Evaluation
After 4 hours of
nursing
intervention the
goal was met as
manifested by
1.Does the client
able to state 2 out
3 situation and
individual
treatment and
safety measures.
_ Yes , _No.

-Determine
diagnosis that
contributes to
immobility.

-Schedule
activities with
adequate rest
periods during the
day.

-To reduce fatigue

2. Does the client

able to
demonstrate
techniques that
enable resumption
of activities
_Yes, _ No.

-Identify energy
conserving
techniques for
ADLs.

-Limits fatigue ,
maximizing
participation

3. Does the client

able to mention 2
out 3 energy
conserving

techniques for
ADLs.
_Yes , _No.

-Maintain or
increase strength
and function of
affected and / or
compensatory
body part.

-Encourage
participation in
self care;
occupational
diversional , or
recreational
activities

-Enhances self
concept and
sense of
independence

-Establish
Rapport

-Gain trust of the

patient

-Get the initial

Vital Signs
-Assist patient in
passive ROM

-Encourage Rest
and provide quiet
& relaxing
environment

-To have baseline

data
-Exercise muscles
and prevent
pressure ulcers.
-Promote rest and
relaxation

-Treat the

4.Does the client

able to participate
in self care or
recreational
activities .
_Yes , _No.

Assessment

Diagnosis

Planning

S/O
(+) Grimace
(+) positioning to
avoid pain

Acute Pain related After 4 hours of

to underlying
nursing
disease.
intervention the
patient will have
reduced pain as
manifested by

-Administer
medicines as
order by the
doctor

underlying cause

Nursing
Intervention

Rationale

Evaluation

-Establish rapport

- To gain trust of
the client
- to have a
baseline data
-Helps in
alleviating pain

After 4 hours of
nursing
intervention the
goal was met as
manifested by

Helps in
alleviating pain

1. A pain scale
lower than 4

- Acquire Vital
signs
-Provide clients
safety and
comfort

1.pain scale grade

of 4 (1 being the
-Encourage
lowest )
relaxation &
diversion
2. (-) grimace
techniques
-Health Teaching
3. (-) positioning
to avoid pain
-Administer
medications as
prescribed by the

(-) grimace
(-) positioning

physician