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Assessment Diagnosis Planning Interventions Rationale Evaluation Subjective: "Maglisod Man Kog Short Term: Independent: - Establish Rapport

The patient reported difficulty moving and walking due to discomfort and left leg swelling. On examination, the patient had impaired mobility, discomfort, left leg swelling, and inability to move without assistance. The short term goals were for the patient to participate willingly in necessary activities after 4 hours and demonstrate decreased signs of intolerance after 1 day. The interventions included establishing rapport, monitoring vitals, turning every 2 hours, maintaining proper body position, giving medicine before activity, and assisting with activities. The rationale was to promote cooperation, obtain baseline data, prevent bed sores, reduce muscle stiffness, and protect from injury. After 5 hours of intervention the goal was partially met.

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Sergi Lee Orate
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159 views3 pages

Assessment Diagnosis Planning Interventions Rationale Evaluation Subjective: "Maglisod Man Kog Short Term: Independent: - Establish Rapport

The patient reported difficulty moving and walking due to discomfort and left leg swelling. On examination, the patient had impaired mobility, discomfort, left leg swelling, and inability to move without assistance. The short term goals were for the patient to participate willingly in necessary activities after 4 hours and demonstrate decreased signs of intolerance after 1 day. The interventions included establishing rapport, monitoring vitals, turning every 2 hours, maintaining proper body position, giving medicine before activity, and assisting with activities. The rationale was to promote cooperation, obtain baseline data, prevent bed sores, reduce muscle stiffness, and protect from injury. After 5 hours of intervention the goal was partially met.

Uploaded by

Sergi Lee Orate
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Impaired physical Short Term: Independent: Goal was met.


“Maglisod man kog mobility related to After 4 hours of - Establish rapport -To promote
takilid takilid inig discomfort nursing cooperation
higda nako. Lisod intervention,
sad ko ug lakaw patient will be able -Monitor vital signs -To have a baseline
lakaw” as to participate data
verbalized by the willingly on
patient necessary/desired -Turn patient every -To prevent bed
activities. 2 hours sores
Objective:
-discomfort Long Term: - Maintain - Improving the
-left leg swelling After 1 day of proper body functional position
-can’t move nursing position of the limb and
without assistance intervention, prevent
patient will be able contractures.
to demonstrate a
decrease in -Give the medicine - Reducing muscle
physiologic signs of before the activity / stiffness and
intolerance exercise. tension enables the
patient to be more
active and help
participation.
- Note the -Edema can
circulation, affect circulation in
movement and the extremities,
sensation in the which is the
lower extremities potential for tissue
often. necrosis.

-Assist patient with -To protect from


activities injury

-Plan care with rest -To decrease


periods between fatigue & to
activities and manage activity
increase activity within limits
gradually
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Activity intolerance Short Term: Independent: Goal was partially
-- related to After 5 hrs of - Establish rapport -To promote met.
Objective: immobility nursing cooperation
-body weakness intervention,
-weak in patient will be able -Monitor vital signs -To help to
appearance to do ADLs alone determine patient’s
-facial grimace and participate in current health
when moving self-care activities. status
-cannot perform
ADLs Long Term: -Assist patient with -To protect from
s After 2 days of activities injury
nursing
intervention, -Assess ability to do -To determine
patient will be able ADLs patient’s capacity
to maintain normal
activity level and a -Assist in -To maximize full
decrease in performing range strength
physiologic signs of of motion exercises
intolerance

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