Jeyser T. Gamutia BN4B Patient’s Name: JM Age: 48 y.o.

8 y.o. Dx: Mild head injury secondary to vehicular accident Date: 10/01/18

Assessment Nursing Diagnosis Rationale Desired Outcomes Nursing Interventions Justification Evaluation

Subjective: Impaired physical Predisposing Factor: After 8 hours of (Independent)

mobility related to
Age: 48 y/o
loss of integrity
“Indi ko mag giho kay of bone structures Gender: Male
kasakit” (fracture)
Objective:
Definition:
Limited range of motion
Impaired Physical
Mobility: Limitation in
independent, purposeful
Slow movements
physical movement of
the body or of one or
more extremities.
With bandage at Left
arm
nurse-patient
 Determine the - To assess functional
interaction, the patient
degree of mobility
will be able to:
immobility in
relation to
suggested scale
Trauma 1. Verbalize
understanding of
(Vehicular accident) the situation and
 Determine
individual treatment
presence
regimen and safety - To assess presence
Fracture of the left of complications
measures of complications
arm related to
immobility
(pneumonia,elimin
2. Participate in ADLs
bleeding from ation problems,
and desired decubitus)
damaged ends of bone activities
and surrounding tissue

Client appears to be  Assist client

3. Maintain position of reposition self on a
disoriented stimulates function and skin
inflammatory response regular schedule
integrity.

Vital signs:
increased capillary  Support affected - To promote optimum
BP: 100/70 mmhg 4. Maintain and body part using level of function and
permeability increase strength pillows. prevent complications
T: 36.4 °C and function of
P: 60 bpm affected part
fluid and
cellular exudation  Provide and assist - To maintain position
R: 22 cpm
with mobility by and function and reduce
means of risk of pressure ulcers.
 Pain wheelchair,
walker, crutches,
Strengths: - Early mobility reduces
canes as soon as
complications of bed rest
Strong family support. impaired physical possible. Instruct
(phlebitis) and promotes
mobility in safe use of
Compliance to healing and normalization
mobility aids.
medications. of organ function.
Learning the correct way
to use aids is important to
Weakness: maintain optimal
mobility and patient
Financial crisis. safety.