Mardy O.

Malinao BSN 3Y2-2B

ASSESSMENT DIAGNOSIS
Subjective: Nahihirapan syang igalaw ang kaliwang parte ng katawan nya as verbalized by the patients relative. Objective: GCS of 12/15 Patient appears weak Spends most time in bed Unable to perform some ADL Activity intolerance related to left sided body weakness as manifested by decreased ROM.

BACKGROUND KNOWLEDGE Traumatic head injury at the right side of the brain Motor nerve got injured Decreased oxygen circulation on the right side of the brain Decreased impulses between the brain and the muscle tissues Decreased motor activity Body weakness occur

PLANNING
Within 4 days of nursing interventions, the patient will be able to demonstrate an increase in activity tolerance on the affected side as evidence by performing some simple ADLs

INTERVENTION
Assess patients ability to perform. Assist and maintained passive and active ROM by allowing patient to do as much as he can. Ensure safety while performing ADLs. HOB at 30 elevations.

RATIONALE
Influence of choice of interventions assistance. Help patient in performing ADL at the same time self-esteem is enhanced by doing thing for self. To avoid patient to falls or have an injury while doing the task. Enhances lung expansion to maximize oxygenation for cellular uptake. For proper therapeutic management of muscle weakness.

EVALUATION
After 4 days of nursing interventions, the patient have been demonstrate an increase in activity tolerance on the affected side as manifested by performing some simple ADLs

GOAL WAS MET!

Keep rested for referral to PMRs for physical therapy.