PUA, ORTHEZA ABEGAIL A.

GROUP 18- BSN II-A3

GOAL & OUTCOME CRITERIA After 8 hours of rendering appropriate nursing interventions the patient will be able to: -Performs physical activity independently or with assistive devices as needed. - Regain or maintain mobility at the highest possible level. NURSING ACTIONS & NURSING ORDERS Independent -.Assess patient or caregivers knowledge of immobility and its implications. -assess degree of mobility produced by injury or treatment and note patients perception of immobility. Dependent -keep the leg elevated as prescribed by the physician.

CUES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

RATIONALE

EVALUATION

Impaired Objective physical cues: mobility related -received to prescribed patient lying movement on bed, restriction. awake, coherent, & responsive. With left leg elevated on pillow. -v/s: BP:130/80 mmHg T: 37.5C P: 60bpm R: 20cpm Physical exam: (+)edema on left leg.

Edema usually results from an imbalance of forces controlling fluid exchange, including an alteration in capillary hemodynamics favoring the retention of sodium and water by the kidneys and the movement of fluid from the vascular space into the interstitium. (www.aafp.org)

-Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebiti s, constipation, pneumonia, and depression. - appropriate measures will be implemented to prevent infections and complications. -To lessen swelling related to the buildup of fluid.

After 8 hours of rendering appropriate nursing interventions the patient was able: -Performs physical activity independently or with assistive devices as needed. But wasnt able to maintain mobility at possible level. Therefore: Goal was only half met.

Collaborative - consult with physical or occupational therapist as indicated.