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ASSESSMENT Subjective: Hindi ako masyadong makagalaw pag nakahiga ako.

as verbalized by the patient



INTERVENTIO N >Monitor vital signs and record

RATIONALE >to obtain baseline data


Impaired bed After series of mobility related nursing to muscular interventions, weakness the patient will secondary to maintain or disease increase condition as strength and evidenced by function of the ASSESSMENT NURSING range ofPLANNING Objective: limited body DIAGNOSIS motion >limited range Objective: of motion Risk for After 8 hours constipation of nursing Slowed related to intervention >slowed movement movement insufficient the patient physical will able to Difficulty >difficulty activity maintain turning turning from usual side to side pattern of Decreased bowel fluid intake functioning.

After series of nursing interventions, >to identify the patient >Determine causative/ maintained or diagnoses that contributing increased contribute to factors strength and immobility function of the INTERVENTIONS RATIONALE EVALUATION body >Note presence >to assess of functional Monitor vital signs To obtain After 8 hours complications ability and to baseline of nursing relatedrecorded. data. intervention immobility >to reduce the patient >Observe skin friction, was able to Discuss usual maintain safe for reddened maintain elimination pattern areas/shearing. skin/ tissue To identify usual and individual Provideuse of pressures, and pattern of appropriate wick away risk laxative. bowel pressure moisture factors/needs Auscultate relief/surface functioning. support abdomen for Reflecting mattress presence, location, bowel and characteristics activity. >Observe for >to adjust care of bowel change in sounds. indicated as strength to do Evaluate current more/less selfdietary and fluid care >to promote intake and optimal level ofidentify To implications forfunction and >Assist with individual activities on bowelprevent effect of risk factors or hygiene, complications function. needs. toileting, feeding as > to promote indicated. optimal level of function and prevent >Provide complications

Instruct/encourage d balance fiber and bulk in diet.

To improve consistency of stool and facilitate passage through the colon.

Promote adequate fluid intake, including water and high-fiber fruit juices: suggest drinking warm, stimulating fluids. Ascertain frequency, color, consistency, amount of stools.

To promote soft stool.

To provide a

baseline for comparison, promotes recognition changes. May help reduce concerns/anx iety about

Discuss physiology and acceptable variations in elimination.

Review appropriate use of medications. Review individual risk factors/ potential problems and specific interventions.

situation. To promote wellness. To promote wellness.