NURSING CARE PLAN

Problem: Body weakness

Nursing Diagnosis: Impaired physical mobility related to decreased strength/endurance
Taxonomy: Activity Exercise Pattern
Cause Analysis: Decrease in strength in muscles in any part of the body can lead to immobilization. Decreased in strength may be due to inefficient
circulation of blood to a part of the body. [Medical Surgical Nursing By Smeltzer and Bare]
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: STO: Independent: 1. Identifies probable

“Maglisod na man siya After 4 hours of
iug lihok,hina na kayo siya” effective nursing
as verbalize by the SO intervention the patient will
regain normal mobility as
evidenced by ability to
move within the physical
Objectives: environment
• the patient is weak
• minimized
movements LTO:
• have limited ROM Within shift the patient
activity will maintain/increase
• needs assistance in strength and function of
positioning in bed affected or compensatory
• inability to ambulate body parts as evidenced by
coordination, normal ROM,
• stays in bed most of
and increased muscle
the time
strength.
Ref: Fundamentals of Nursing by Kozier p.168
1. Reviewed functional functional
abilities and reasons for impairments and
impairment. influences choice of STO:
2. Provided assistance for intervention Not met.
ROM exercise 2. Maintains mobility
3. Provided meticulous and functions of
skin care, managing joints alignment of
with lotions. Remove extremities and
wet linens, keep reduces venous
bedding free of wrinkles stasis
4. Kept necessary utensils 3. Promote circulation
within reach of the and reduces risk of
patient skin excoriation
5. Encouraged patient to 4. Keeping all in reach, LTO:
do self care activities can greatly reduce Not met
such as oral care, the risk of accident to
walking exercise the patient.
5. This is to enable the
patient to regain
muscle strength and
keeping himself
clean, and will gain
independence