Name: Baile,Corazon y name of patient: Cristina Garcia

Bsn 3-E Diagnosis: Motor Vehicular Accident

Malolos physical therapy and rehabilitation center

Mr. jonh paul Mendoza R,N

Assessment Nursing Scientific Planning Implementation Rationale Evaluation

Diagnosis Knowledge
Subjective data: Dependent: After 2-3 hours of
 “Nahihirpan Impaired Vehicular Short term goal:  Instruct the For position nursing
akong physical accident In 2-3 hours of nursing patient to use changes or interventiongoals
kumilos.” As mobility r/t interventions the client assistive transfer. to maintainor
verbalized by musculoskelet Injuries of will be able to maintain device like increase strength
the patient. al impairment face and or increase strength siderails or and function of
as evidenced extremities and function of affected wheelchair. affected body
Objective data: by decrease body parts as evidenced  Support To maintain parts were met as
 Slowed muscle Inflammatio by: affected body position function evidenced by:
movement of strength. n 1. Verbalize parts or joint and reduced risk 1. Ability to
both upper understanding using pillow, of pressure ulcer. move the
and lower Impaired of situation and rolls, t affected
extremities. physical individualtreat support. body parts
 Difficulty movement. ment regimen  Provide for To prevent the without
turning and safety safety patient from discomfort
 Limited range measures. measure as injury. 2. Verbalized
of motion of 2. Ability to move indicated by understan
both upper the affected individual ding the
and lower body parts situation situation
extremities. without including and
discomfort. environmenta individual
3. Demonstrate l management treatment
technique or and full regimen
behaviors that prevention. and safety
enable  Provide To maintain the measure
 resumption of regular skin patient integrity. Demonstrate
activities. care to technique or
Long term goal: include behaviors that
After 2-3 weeks of pressure area enable
nursing intervention the management. resumption of
patient will be able to  Encouraged To promote well activities.
improve physical the patient being and 3. Ability to
mobility as evidenced adequate maximized energy performed
by: intake of production. ROM
 Ability to fluids and exercise.
performed nutritious
ROM exercise. food.
 Participate  Encouraged To promote
ADLs and the patient to proper circulation
desired have regular of blood in the
activity. exercise. body.
 Maintain  Ssscheduled To reduce fatiue.
position of activities with
function and adequate rest
skin integrity period during
as evidenced the day.
by absence of Independent:
contracture,  Assist To promote the
footdrop, or patient progress.
decubitus. have
 Ability to walk the
the patient patien
without t
assistive reposi
device. tion
self on
a
regula
r
 sched
uled
as
dictat
ed by
individ
ual.
 Perfor To promote
med patient muscle
ROM strength
exerci
se as
doctor
’s
ordere
d.
 Perfor To promote
med healing process.
warm
compr
ess as
doctor
’s
odere
d.