Emilio Aguinaldo College

College of Nursing and Midwifery

ASSESSMENT MINI NURSING GOAL/PLANNING INTERVENTION RATIONALE EVALUATION

PATHOPHYSIOLOG DIAGNOSIS
Y

Subjective: Fall from 15 ft high Alteration of After 8 hours of -Checked the -To check for the Goal Met. After 8
“Namamanhid and landed with his sensory nursing color of the skin circulation. hours of nursing
yung buong braso left shoulder. perception interventions the of the affected interventions the
ko.” related to limited patient will be arm. patient had
ability to perform able to identify identified
Objective: Shoulder joint motor skills. awareness of -Measured -To check for the awareness of
-(+) pain damage sensory capillary refill. circulation in the sensory
-Weak Pulse perception. affected area. perception.
-Delayed capillary -Monitored vital -To have baseline
refill (5 seconds) Local swelling and signs. data.
tissue hypertrophy
around the -Teached the -To enhance
shoulder. patient about circulation in the
passive exercises. affected area.

Ulnar nerve -Encouraged -To decrease

compression patient to use tension level.
relaxation
techniques (deep
breathing
exercises)
 -Evaluated -May indicate
Limited body sensory decrease
movement awareness: peripheral
stimulus of circulation.
dull/sharp
Numbness