Philippe Steven Go

BN4H

ASSESSMENT

NURSING DIAGNOSIS

RATIONALE

DESIRED OUTCOME After hours of nursing intervention the client will be able to :

NURSING INTERVENTION

JUSTIFICATION

EVALUATION After hours of nursing intervention the client was able to:

Actual Abnormal cues: Body Malaise Weakness Fatigue Dizziness Limited range of motion, limited ability to perform gross and fine motor skills Difficulty in turning Difficulty in changing positions Risk Factors: Sedentary lifestyle Stress / Depression

Predisposing Precipitating Impaired physical factors: factors: mobility R/T fracture - Age - Sedentary of left leg AEB limited - Gender Lifestyle range of motion, - Family - Stress limited ability to History perform gross and fine motor skills and pain during movements Vasoconstriction of blood vessels

Independent 1. Demonstrate an increase in activity tolerance Encourage participation and self care, occupational, divertional, recreational activities. Enhances self concept and sense of independence.

Decreased oxygen supply

Definition: Limitation in independent purposeful physical movement of the body or one or more extremities

Failure to nourish the tissue at capillary level

Blood vessels impaired

Decreased blood supply to the different parts of the brain and the body

Strength(s): Strong family support

Source: Nurses Pocket Guide Eleventh Edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C.

2.Demonstrate behavior to reduce risk factor and protect self from injury

weakness, fatigue, dizziness

Monitor movements of the client if there are any improvements or deterioration in his bodys functioning.

Impaired physical mobility

To note the physical status and capacity of the client to move and perform activities, basis for further plans of daily activities.

Close relationship with God Good compliance to medication

Geissler-Murr Source: http://www.scribd.com 3. Increase strength and function of compensatory body part

Perform active and passive ROM exercises in all extremities several times daily Schedule activities with adequate rest period during the days Encourage adequate intake of fluids or nutritious food

These preserve and increase muscle strength

To reduce fatigability

Promote well being and maximize energy production

Collaborative: Consult with physical/occupationa l therapist as indicated. To develop individual exercise/ mobility and identify appropriate devises To prevent further complications.

Assist with treatment of underlying condition causing pain and dysfunction.

Source: Nurses Pocket Guide Eleventh Edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr

Source: Nurses Pocket Guide Eleventh Edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr