assessment SUBJECTIVE: Nadulas ako sa hagdan, hindi ako makalakad (I slipped down the stairs and now I cant

walk) as verbalize by the patient OBJECTIVE: Limited range of motion Decreased muscle strength Inability to move purposefully V/S taken as follows T: 37.1 C P: 82 R: 18 BP: 120/ 100

Nursing diagnosis Impaired physical mobility related to neuromuscular skeletal impairment

Planning After 8 hours of nursing intervention the patient will regain or maintain mobility at the highest possible level.

Intervention Independent: Assess degree of mobility produced by injury or treatment and note patients perception of immobility. Encourage participation on diversional or recreational activities. Instruct patient in assisting in active or passive range of motion exercises of affected and unaffected extremities. Provide footboard. Assist with or encourage selfcare activities. Reposition periodically and encourage coughing or deep breathing exercises. Encourage increased fluid intake to 20003000 mL/day (within cardiac tolerance), including acid/ash juices. Collaborative: Refer to a therapist as indicated

Rationale Patient may be restricted by selfview or selfperception out of proportion with actual physical limitations requiring interventions to promote progress toward wellness. Provides opportunity for release of energy, refocuses attention, enhances patients self control or self worth and aids in reducing social isolation. Increases blood flow to muscle and bone to improve muscle tone, maintain joint mobility; prevent contractures or atrophy and calcium resorption from disease. Useful in Maintaining of extremities, preventing complication. Improve muscle strength and circulation, enhances patient control in situation, and promotes selfdirected wellness. Prevents or reduces incidence of skin and respiratory complication. Keeps the body well hydrated, decreasing the risk of urinary

*infection, stone formation, and constipation. Done to promote bowel evacuation.

SUBJECTIVE: Nahihirapan ako magsalita, as verbalized by the client. OBJECTIVE: BP: 150/100 PR: 74 RR: 30 T: 36.4 As manifested by: Difficulty producing speech. Facial paralysis. Muscle and facial tension.

Impaired verbal communication related to loss of facial or oral muscle tone control.

After 1 hr. of nursing intervention, the patient will establish method of communication in which needs can be expressed. evaluation After 1 hr. of nursing intervention, the patient was able to establish method of communication in which needs can be expressed.

Provide alternative methods of communication, like pictures or visual cues, gestures or demonstration. Anticipate and provide for patients needs. Talk directly to patient. Speaking slowly and directly. Use yes or no question to begin with. Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Encourage family members and visitors to persist efforts to communicate with the patient.

Provide communication needs or desires based on individual situation or underlying deficit. Helpful in decreasing frustration when dependent on others and unable to communicate desires. It reduces confusion or anxiety and having to process and respond to large amount of information at one time. Patient is not necessary hearing impaired and raising voice may irritate or anger the patient. It is important for family members to continue talking to the patient to reduce patients isolation, promote establishment of effective communication and maintain sense of connectedness or bonding with the family.