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BN4H
ASSESSMENT
NURSING DIAGNOSIS
RATIONALE
DESIRED OUTCOME After hours of nursing intervention the client will be able to :
NURSING INTERVENTION
JUSTIFICATION
EVALUATION After hours of nursing intervention the client was able to:
Actual Abnormal cues: Body Malaise Weakness Fatigue Dizziness Limited range of motion, limited ability to perform gross and fine motor skills Difficulty in turning Difficulty in changing positions Risk Factors: Sedentary lifestyle Stress / Depression
Predisposing Precipitating Impaired physical factors: factors: mobility R/T fracture - Age - Sedentary of left leg AEB limited - Gender Lifestyle range of motion, - Family - Stress limited ability to History perform gross and fine motor skills and pain during movements Vasoconstriction of blood vessels
Independent 1. Demonstrate an increase in activity tolerance Encourage participation and self care, occupational, divertional, recreational activities. Enhances self concept and sense of independence.
Definition: Limitation in independent purposeful physical movement of the body or one or more extremities
Decreased blood supply to the different parts of the brain and the body
Source: Nurses Pocket Guide Eleventh Edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C.
2.Demonstrate behavior to reduce risk factor and protect self from injury
Monitor movements of the client if there are any improvements or deterioration in his bodys functioning.
To note the physical status and capacity of the client to move and perform activities, basis for further plans of daily activities.
Geissler-Murr Source: http://www.scribd.com 3. Increase strength and function of compensatory body part
Perform active and passive ROM exercises in all extremities several times daily Schedule activities with adequate rest period during the days Encourage adequate intake of fluids or nutritious food
To reduce fatigability
Collaborative: Consult with physical/occupationa l therapist as indicated. To develop individual exercise/ mobility and identify appropriate devises To prevent further complications.
Source: Nurses Pocket Guide Eleventh Edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr
Source: Nurses Pocket Guide Eleventh Edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr