NURSING MANAGEMENT

ASSESSMENT NURSING
PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Impaired physical After 30 minutes of  Assist in range of - promote and enhance After 30 minutes of
“Masakit po yung mobility related to continuous nursing motion activities good blood circulation, continuous nursing care,
kamay ko at hindi ko musculoskeletal care, the patient will be on the affected and maintain muscle tone the patient was able to
maigalaw” As impairment as able to demonstrate unaffected and prevent muscle demonstrate techniques
verbalized by the manifested by techniques that will extremities. atrophy. that will enable
patient.  Irritability enable resumption of resumption of activity.
 Limited activity.  Perform - evaluate degree of
movement continuous injury and to assess
 Guarding assessment of choice of intervention to
behavior motor function by be done
 Muscle requesting patient
Objective: weakness to perform certain
 Irritability actions.
 Limited
movement  Reposition patient -reduce pressure areas
 Guarding periodically. and promote good
behavior upon circulation
moving
 Muscle  Provide diversional - to divert client’s
weakness activities and attention from stress or
encourage anxiety and to exercise
V/S: involvement within client’s mind
RR: 19cpm patient’s tolerance
HR: 80 bpm or ability
T: 36.8c  Inspect skin daily -to prevent further
and observe for complications that may
pressure areas, bed aggravate patient’s
sores and provide current health condition
appropriate skin
care
 ASSESSMENT NURSING
PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Activity intolerance After 8 hours of duty,  Evaluate client’s - To provide baseline After 8 hours of duty,
“Hindi nya magalaw related to the patient will be able actual perception data and to assess type the patient was able to
yung kaliwang kamay musculoskeletal to demonstrate signs to and limitation of and choice of demonstrate signs to
nya” as verbalized by impairment as cooperate and decrease ability. intervention cooperate and decrease
the patient. manifested by: physiologic sign of physiologic sign of
 Muscle intolerance.  Note client’s report - to evaluate symptoms intolerance.
weakness of pain, weakness that may have
 Irritability and difficulty in contributed to patient’s
 Guarding accomplishing task intolerance
Objective: behavior or activities.
 Muscle  Limited
weakness movement  Encourage - assist client to deal
 Irritability expression of with contributing factors
 Guarding feeling regarding and manage activities
behavior her condition within individual’s
 Limited limits
movement
 Assist with - to protect patient from
activities and injury
V/S: provide client’s use
RR: 19cpm of assistive
HR: 80 bpm hardware or
T: 36.8c devices.

 Promote comfort - to enhance ability to