ASSESSMENT NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

(Subjective DIAGNOSIS (Dependent,

and Objective) Interdependent,
Collaborative)
Cues: Impaired physical Tuberculous After 2 hours Reposition patient To promote wellness Patient was able to look at
mobility: unable meningitis is an of nursing comfortably and prevent bed sores hand and move it with his
Subjective Cues: to lift left infection of the interventions, other hand.
“Dili na siya maka lihok extremities tissues covering the patient Straighten bed To aid in comfort and
linens sleep
and iyhang wala nakilid.” related to nerve the brain and will be able
as verbalized by the S.O. infection spinal cord to maintain
Give gentle To get good circulation
(meninges). or improve massage to limb
Objective Cues: Tuberculous extremity
-Unable to lift left meningitis is activity. Assist in passive To promote
extremities caused range of motion independence and
by Mycobacterium exercises circulation
-Unable to move his self tuberculosis. This
-Unable to ambulate is the bacteria Placed items on Easy access to items
-Struggling to perform that causes the easiest
ADLs tuberculosis (TB). accessible side of
The bacteria patient
spread to the
brain and spine
from another
place in the body,
usually the lung.

Source:
woundcarecenters.org
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ASSESSMENT NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

(Subjective DIAGNOSIS (Dependent,
and Objective) Interdependent,
Collaborative)
Cues: Altered skin
Bedsores — also called After 8 hours Dependent Patient will
integrity: of nursing Assess client’s ability to Immobility is a huge risk gradually
pressure pressure ulcers and decubitus move factor for pressure ulcer. show signs of
Subjective Cues: interventions
“Naay samad sa ulcers related ulcers — are injuries to skin , the patient wound healing
Assess skin and To know the extent of
to immobility as evidenced
iyahang likod kay sige and underlying tissue resulting will be able characteristics of caring for ulcer.
by color and
siya mo higda.” As to Client will pressure ulcer
from prolonged pressure on the characteristics
verbalized by S.O. experience .
skin. Bedsores most often Turn patient every two To prevent new ulcers
healing of hours from forming and reduce
Objective Cues: develop on skin that covers pressure pressure on ulcer.
12 cm diameter Pressure ulcers and
bony areas of the body, such as
ulcer at lower back experiences Apply cream to To aid in fast healing
Bleeding at lower part of the heels, ankles, hips and pressure pressure ulcer
pressure ulcer reduction.
tailbone. People most at risk of Promote bandaging
Small pressure ulcer hole Moisture aids with healing
below butt crack bedsores are those with a
Place unscented lotion Relieves dry skin and
Ulcers are pink in color medical condition that limits on legs scaling
Exudates present
Scaling, dry skin at legs their ability to change positions
Interdependent
and ankles or those who spend most of Encourage moving any To encourage
part of body or practice independence and
their time in a bed or chair.
turning from side to prevention of future sores
side

Collaborative
With aid of another To be able to provide best
nurse, Pull patient up in positioning with help of
bed by lifting with sheet another
or padding