NAME: Stephen S.

Padayhag DATE: August 23, 2010

CLINICAL INSTRUCTOR: Hiawatha A. Pangarungan AREA: STATION 4-C
LEVEL: BSN – 3 SHIFT: 7am – 3pm
Assessment Diagnosis Planning Intervention Evaluation

Subjective Cues: Impaired physical Short Term: after an hour or  Assist client to learn safety Goals partially met:
so… measures:
Father verbalizes “ Dili ni maka
mobility as evidenced by
 Patient understood the
tindog si welgie kay inig mu dizziness and general  Verbalize of understanding o Use of hands to importance of using
aksyon syag hawa sa katre weakness related to of situation/risk factors and absorb fall. hands to grasp for
unya mu kali tog abot ang sensoriperceptual importance of treatment o Use of hands to grab support to the wall.
tuyok, mag kapuluke cya og impairment, reluctant rendered, and safety nearby firmly
kaput kay malipong man measures. attached objects.  Patient has
siya…” to initiate movement
 Demonstrate techniques o Use of hands to demonstrated this ( as
and environmental that are alternative but stated above)
reach outward to
Mother Verbalizes “…mag stimuli. helpful to ambulation. provide balance and
patabang ka og hawid nak? Pag  Arranged room to her suit quick support on  Removed objects that
saba lang.” –stating that her needs. wall. comes in her way to the
patient W might need  Encouraged patient to use o Ask for support from CR,
assistance ambulating from CR emergency safety watcher.
to Bed. precautions. • Patient is unwilling to
 Involve client/ watcher in
care assisting them to learn perform beyond
Patient Verbalizes “Pasensya Long Term: After 8 hours… demonstration.
ways of managing problems
na kayo, ako lang jud tabunan
of immobility. • Patient verbalizes
ako mata kay mag lipong  Adjust and cope well with  Moved objects that will be “Ikatulog ko nalang ni,
lipong ko.” new temporary lifestyle. on her way when walking to hago hago lang na.”
 Ambulate in a small the CR.
Objective Cues:
distance of 5-8 meters
without assistance from CR
• Patient and watchers report to Bed.
trouble when ambulating.
• Patient report weakness
and nausea when dizziness
attacks.
• Limited movement when
ambulating.
• Limited ability to perform
basic needs.
• Difficulty during ambulation.
• Slowed movement and
decreased reaction time.
• Patient shows signs of
resignation (asks her
mother for a glass of water
given directly to her grasp.)
• Patient places a night shade
over her eyes and ear plugs
on her ears.