Cues Nursing

Diagnosis
Analysis Planning Intervention Evaluation
Subjective:
Ang hirap ng
may ganito
(traction).
Bawal kumilos,
hindi man lang
ako makapunta
sa banyo para
maligo.
Hinihintay ko
pa na may
bisita ako para
lang
makapaglinis
ng sarili ko
verbalied by
the client.
Objective:
!lient is on
modi"ied
buck#s
e$tension
traction.
!lient is on
semi%"owler#s
position.
!lient had
"racture on
the right leg
Impaired
Physical
obility
related to
musculoskelet
al impairment
possibly
evidenced by
inability to
move
purpose"ully
within the
physical
environment,
imposed
restriction.
Impaired Physical
obility
&imitation in
independent,
purpose"ul physical
movement o" the body
or o" one or more
e$tremities.
Alteration in mobility
may be a temporary or
more permanent
problem. 'ost disease
and rehabilitative
states involve some
degree o" immobility
(e.g., as seen in
strokes, leg "racture,
trauma, morbid
obesity, and multiple
sclerosis). (ith the
longer li"e e$pectancy
"or most Americans,
the incidence o"
disease and disability
continues to grow. And
with shorter hospital
stays, patients are
being trans"erred to
rehabilitation "acilities
or sent home "or
physical therapy in the
home environment.
'obility is also related
!oals:
A"ter ) hours o" nursing
intervention, the client
will be able to verbalie
understanding o"
situation and individual
treatment regimen and
sa"ety measures
independently.
Objectives:
A"ter * hour o" nursing
intervention, the client
will be able to+
*.,o identi"y at least
"ive out o" eight
causative-contributing
"actors
..,o report three out o"
"ive o" his "unctional
ability
/.,o e$plain at least
"ive o" the optimal
level o" "unction and
measures on how to
prevent
complications.
0.,o discuss "our out o"
"ive o" wellness
program.
%Assess client#s
developmental level,
motor skills, ease and
capability o" movement,
posture and gait.
%1rovide increase protein
like "ish, "ruits and
vegetables
%assist in "eeding the
client with / meals and .
snacks.
%2ncrease "luid intake
%teach clients on proper
brushing techni3ue to
promote oral hygiene
%encourage regular
gargling
%assist client during
urination and de"ecation
%encourage perineal
hygiene
%1rovide privacy during
toileting
%turn to side every now
and then
%keep skin dry. (ash
gently
%allow client time "or
cultural routines
%assist client to attend
church activities
%Assist-have client reposition sel"
on a regular schedule as
dictated by individual situation
%4emonstrate-assist with use o"
side rails, overhead trapee,
,he goal was met.
'et. ,he client was
able to identi"y "ive
out o" eight
causative-contributin
g "actors.
'et. ,he client was
able to report three
out o" "ive o" his
"unctional ability.
'et. ,he client was
able to e$plain at
least "ive o" the
optimal level o"
"unction and
measures on how to
prevent
complications.
'et. ,he client was
able to discuss "our
out o" "ive o"
wellness program.
to body changes "rom
aging. &oss o" muscle
mass, reduction in
muscle strength and
"unction, sti""er and
less mobile 5oints, and
gait changes a""ecting
balance can
signi"icantly
compromise the
mobility o" elderly
patients. 'obility is
paramount i" elderly
patients are to
maintain any
independent living.
6estricted movement
a""ects the
per"ormance o" most
activities o" daily living
(A4&s). 7lderly
patients are also at
increased risk "or the
complications o"
immobility. 8ursing
goals are to maintain
"unctional ability,
prevent additional
impairment o" physical
activity, and ensure a
sa"e environment.
roller pads, hydraulic li"ts-chairs
%provide-recommend egg%crate,
alternating air%pressure, or water
mattress.
%7ncourage client#s
participation in sel"%care
activities,
%. 9chedule activities with
%Avoid routinely assisting or
doing "or client those activities
that client can do "or sel"
%Administer medications be"ore
activity as needed "or pain relie"
%2nvolve client and 9:(s)
in care, assisting them to
learn ways o" managing
problems o"
immobility, especially when
impairment is e$pected to be
long%term.
%4emonstrate use o"
standing aids and mobility
devices and have
client-careprovider
demonstrate knowledge
about-sa"e use o" device.
2denti"y appropriate
resources "or obtaining
and maintaining
appliances-
e3uipment.