ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S> Mayron Risk for ineffective therapeutic After 15 minutes >Ascertain client To evaluate client’s After 15 minutes of
akong gamot regimen management r/t of nursing knowledge/understanding understanding about nursing intervention and
dati pero di ko knowledge deficits as interventions and of condition and his illness. health teaching client:
tinapos ang manifested by lack of attention health teaching, treatment needs. . >Verbalizes desire to
paginom dahil to illness and its possible client will: >Identify individual For goal setting. achieve wellness.
mabuti naman further complication. >Verbalize perceptions and >Demonstrates efforts to
na ang acceptance of expectations of treatment. comply to appropriate
pakiramdam ko. need/desire to >Provide positive medication
change actions to reinforcement for efforts.
O> Lack of achieve agreed-on
attention to outcomes.
illness, >demonstrate
> Assumes that behaviors/changes
he is feeling in lifestyle
well and can go necessary to
out of the maintain
hospital right therapeutic
away, regimen.

Prepared By: Jose Miguel Bernardo

 Assessment Diagnosis Planning Intervention Rationale Evaluation

Assessment Impaired After 8 hours of Assess degree of > Patient may be Goal met: The
physical mobility nursing immobility produced restricted by self- patient was able
Subjective – r/t restrictive intervention, by treatment and perception out of to regain
“Hindi ako therapy amb patient will be able note patient’s proportion with mobility that his
masyado inability to move to regain mobility perception of actual physical condition
makagalaw dahil purposefully and in an allowable immobility. limitations. allowed.
dito sa ikinabit limited ROM level.
sa paa ko,” as 2. Instruct patient > Increases blood Goal met: The
verbalized by 1. The patient will with active ROM flow to muscles and patient showed
the patient. be able to increase exercises of affected bone to improve increased
strength of and unaffected muscle tone, strength in his
Objective – affected and extremities such as maintain joint affected and
limited ROM compensatory flexion and mobility, and unaffected legs
body parts within dorsiflexion of the prevent as showed by his
L short leg posterior 2 days. toes of the affected contractures or independence in
mold cast leg, and flexion and atrophy. performing
2. The patient will extension of the active ROM
be able to unaffected leg. > Facilitates exercises.
demonstrate movement during
Active ROM 3. Instruct in use of hygiene/skin care Goal met: The
exercises after the overhead trapeze. and linen changes. patient was able
sample to do a return
demonstrations of 4. Encourage self-care > Improves muscle demonstration of
the said exercises. activities such as strength and the active ROM
bathing and oral care. circulation, exercises taught
3. The patient will be enhances patient to him.
able to do self-care control in situation,
activities immediately and promotes self- Goal met: The
after the intervention directed wellness patient was able to
resume with his
self-care activities.