A 55 y.

o male who suffers from right hemiplegia with muscle strength of 0 out of 5 at right upper and lower limbs.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective data: Impaired physical Short term goal: Dependent nursing actions: Short term goal:
- “hindi ko mobility RT to - Within 30 - Collaborate with - to develop - After 30
magamit yung decreased muscle minutes, the physical medicine individual minutes, the
kanang bahagi ng control or strength, as patient will be specialist and exercise and patient is now
katawan ko, evidenced by the able to maintain occupational or mobility pro- able to
simula nung absence of muscle position of physical therapists in gram, to identify maintain
nawalan ako ng strength of right upper function and skin providing range-of- appropriate position of
lakas doon. Mula and lower limbs. integrity as motion exercise mobility function and
braso hanggang evidenced by (active or passive), devices, and to skin integrity as
paa. Sobrang absence of isotonic muscle limit or reduce evidenced by
hina ko na tuloy.” contractures, contractions (e.g., effects and absence of
As verbalized by footdrop, flexion of ankles, complications of contractures,
the patient. decubitus, and so push-and-pull immobility. footdrop,
Objective data: forth. exercises), assistive decubitus, and
- 55y.o male devices, and so forth.
- Suffers from Long term goal: activities (e.g., early Long term goal:
right-sided - Within 1 month, ambulation, - After 1 month,
hemiplegia. the patient will transfers, stairs) the patient is
- Muscle strength be able to now be able to
on the right side maintain or - Administer - to permit maintain or
is rated as 0 out increase strength medications prior to maximal effort increase
of 5. and function of activity as needed and strength and
- No observable affected and/or for pain relief. involvement in function of
movement or compensatory activity. affected and/or
muscle body part. Independent Nursing compensatory
contraction in Actions: body part.
the right upper
and lower limbs
during - Assist with - to maximize the
examination. treatment of potential for
underlying condition mobility and
causing pain and/or function.
dysfunction .
- to maintain
- Support affected position of
body parts or joints function and
using pillows, rolls, reduce risk of
foot supports or pressure ulcers.
shoes, gel pads,
foam, etc., - Reduces tissue
pressure and
- Provide or aids in
recommend maximizing
pressure-reducing cellular
mattress, such as perfusion to
egg crate, or prevent dermal
pressure-relieving injury.
mattress, such as
alternating air - Promotes
pressure or water. safety and
independence
- Demonstrate use of and enhances
standing aids and quality of life.
mobility devices
(e.g., walkers,
strollers, scooters,
braces, prosthetics)
and have client/care
provider
demonstrate
knowledge about,
and safe use of
device. Identify
appropriate
resources for
obtaining and
maintaining
appliances and
equipment.
A 55 y.o male who suffers from right hemiplegia with muscle strength of 0 out of 5 at right upper and lower limbs.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective data: Impaired physical Short term goal: Dependent nursing actions: Short term goal:
- “hindi ko mobility RT to - Within 2 hours, - Collaborate with - to develop - After 2 hours,
magamit yung decreased muscle the patient will physical medicine individual the patient is
kanang bahagi ng control or strength, as be able to specialist and exercise and now able to
katawan ko, evidenced by the maintain position occupational or mobility pro- maintain
simula nung decreased gross motor of function and physical therapists in gram, to identify position of
nawalan ako ng skills. skin integrity as providing range-of- appropriate function and
lakas doon. Mula evidenced by motion exercise mobility skin integrity as
braso hanggang absence of (active or passive), devices, and to evidenced by
paa. Sobrang contractures, isotonic muscle limit or reduce absence of
hina ko na tuloy.” footdrop, contractions (e.g., effects and contractures,
As verbalized by decubitus, and so flexion of ankles, complications of footdrop,
the patient. forth. push-and-pull immobility. decubitus, and
Objective data: exercises), assistive so forth.
- 55y.o male Long term goal: devices, and Long term goal:
- Suffers from - Within 1 month, activities (e.g., early - After 1 month,
right-sided the patient will ambulation, the patient is
hemiplegia. be able to transfers, stairs) now be able to
- Muscle strength maintain or maintain or
on the right side increase strength - Administer - to permit increase
is rated as 0 out and function of medications prior to maximal effort strength and
of 5. affected and/or activity as needed and function of
- No observable compensatory for pain relief. involvement in affected and/or
movement or body part. activity. compensatory
muscle Independent Nursing body part.
contraction in Actions:
the right upper
and lower limbs
during - Assist with - to maximize the
examination. treatment of potential for
underlying condition mobility and
causing pain and/or function.
dysfunction .
- to maintain
- Support affected position of
body parts or joints function and
using pillows, rolls, reduce risk of
foot supports or pressure ulcers.
shoes, gel pads,
foam, etc., - Reduces tissue
pressure and
- Provide or aids in
recommend maximizing
pressure-reducing cellular
mattress, such as perfusion to
egg crate, or prevent dermal
pressure-relieving injury.
mattress, such as
alternating air - Promotes
pressure or water. safety and
independence
- Demonstrate use of and enhances
standing aids and quality of life.
mobility devices
(e.g., walkers,
strollers, scooters,
braces, prosthetics)
 and have client/care
provider
demonstrate
knowledge about,
and safe use of
device. Identify
appropriate
resources for
obtaining and
maintaining
appliances and
equipment.

A 33y.o female who was involved in a minor vehicular accident had a fracture on her left distal phalanges, with pain at the fractured site with pain rating scale of
4/10, with bruises at left leg and inflamed left foot.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective data: Decreased activity Short term goal: Dependent nursing actions: Short term goal:
“Nararamdaman ko po tolerance related to - Within an hour, - Provide referral to - to develop - After an hour, the
yung sakit ng kanang pain of fractured the patient will be other disciplines, individually patient is now
daliri ko nung na phalanges as able to Report such as exercise appropriate able to Report
aksidente ako, evidenced by measurable physiologist, therapeutic measurable
nakakayanan ko pa reported pain scale increase in psychological regimens. increase in
naman yung sakit, pero of 4/10. activity counseling/therapy, activity tolerance.
siyempre hindi ko pa tolerance. occupational/physical Long term goal:
din siya maigagalaw at therapists, and - After 7 days, the
magagamit ng maayos. Long term goal: recreation/leisure patient is now
Problema ko pa din - Within 7 days, the specialists, as able to
paano ako kikilos ng patient will be indicated, participate
may ganitong fracture able to willingly in
sa daliri ko.” As participate - Administer - Type of necessary/desired
verbalized by the willingly in medications, as medication is activities.
patient. necessary/desired indicated. dependent on
Objective data: activities. the underlying
- 33y.o female conditions and
who had a Independent Nursing might include
minor vehicular Actions: medications.
accident.
- Fractured left - Promote comfort - to enhance
distal phalanges measures and ability to
with pain scale provide for relief of participate in
of 4/10. pain activities.
- With visible
bruised left leg. - Ascertain the client’s
- With visible ability to stand and - to determine
inflamed left move about and the current status
foot. degree of assistance and needs
- Limited necessary or use of associated with
movement with equipment. participation in
her hand and needed/desired
left foot. activities.

- Give client
information that - to sustain
provides evidence of motivation.
daily/ weekly
progress.

- Assist client in - to prevent