NCP PROPER

CUES EXPLANATION OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

OF THE
PROBLEM
S> “mahirap kasi Impaired Physical STO>  Determine diagnosis that  These conditions can The goal was met.
di ko nagagalaw Mobility After 8 hours of contributes to immobility. cause physiological
yung kaliwang paa Limitation in nursing and psychological *Met- the client able to
ko” independent intervention, the problems that can verbalize understanding of
purposeful client will be able seriously impact situation and individual
O> physical to verbalize physical, social, and treatment regimen and
-unable to move movement of the understanding of economic well-being. safety measures.
left arm and body or of one or situation and  Note factors affecting current  Identifies potential
fingers. more extremities. individual situation and potential involved. impairments and -Met if client able to
-unable to Alteration in treatment regimen determines types of maintain or increase
reposition self to mobility may be a and safety interventions needed strength and function of
bed. temporary or more measures to provide for client’s affected pr compensatory
-needs partial permanent independently. safety. body part.
assistance in problem. Most  Determine degree of immobility  Identify strengths and
ADL’s. disease and LTO> in relation to 0-4 scale, noting deficits impaired -Partially met if client
-muscle strength rehabilitative -after 2 days of muscle strenght and tone, joint physical mobility and difficult to increase
of 2/5 at left leg states involve nursing mobility and endurance. may provide strength and function of
and 1/5 at left arm. some degree of intervention, information regarding affected body part.
immobility. With patient will able to potential for recovery.
Nursing diagnosis: the longer life maintain or  Note emotional/behavioral  Can negatively affect -Unmet if client not fully
-Impaired physical expectancy for increase strength responses to problems of self-concept and self- able to maintain or
mobility related to most Americans, and function of immobility. esteem, autonomy, increase strength and
musculoskeletal the incidence of affected or and independence. function of affected body
impairment. disease and compensatory Feelings of frustration part.
disability continues body part. and powerlessness
to grow. In shorter may impede *Therefore the goal was
hospital stays, attainment of goals. partially met.
patients are being Social occupational,
transferred to and relationship roles -Met if client will able to
rehabilitation can change, leading to participate both in ADL’s
facilities or sent isolation, depression, and desired activities.
home for physical and economic
therapy in the consequences -Partially met if client just
home  Assist client reposition self.  To enhance circulation only able to participate in
environment. to tissues, reduce risk desired activities.
of tissue ischemia.
 Support affected body parts  To maintain position of -Unmet if client not able to
using pillows/rolls, foot function and reduce participate in ADL’s and
supports. risk of pressure ulcers. desired activities.
-after 3 days of  Ensure safety like use of side  To prevent fall or injury
nursing rails. to client. *Therefore goal was
intervention,  Encourage client’s participation  To enhance self- partially met.
patient will able to in self-care activities, physical concept and sense of
participate in therapies independence, and
ADL’s and desired improves body
activities. strength and function.
 Encourage significant others to  To promote circulation
do passive ROM. and prevent atrophy of
legs.
 Cues Explanation of Goals and Nursing intervention Rationale Evaluation
the problem objectives
S> Self-Care Deficit STO>  Assess the patient’s strength  The patient may only The goal was met.
“hindi ko Impaired ability After 8 hours of to accomplish ADL’s need help with some
nagagawang to perform or nursing efficiently. self-care measures. Met :the client able to
pumunta sa CR complete intervention  Guide the patient in  Patient may require identifies useful
at mga gusto activities of daily patient will able accepting the needed help in determining resources in optimizing
kung gawin nga living for oneself, to amount of dependence. the safe limits of teh autonomy and
dahil sa such as feeding , identifies useful trying to independent independence.
kalagayan ko” dressing, resources in versus asking for
bathing, and optimizing the assistance when
O> toileting. autonomy and necessary.
-unable to dress Activities of daily independence.  Implement measures to  An appropriate level -Met if client able
self and take off living are defined LTO> promote independence, but of assistive care can demonstrates lifestyle
clothing as “the stuff we After 3 days of intervene when the patient prevent injury from changes and safely
autonomously. regularly do such nursing cannot function. activities without executes self-care
-unable to move as feeding intervention causing frustration. activities.
form bed to ourselves, patient will able  Boost maximum  The goal of
wheelchair bathing, to: independence rehabilitation is one -partially met if client
-unable to dressing, -demonstrates of achieving the slowly executes self-
access grooming, work, lifestyle changes highest level of care activities to utmost
bathroom. homemaking and to meet self-care independence capability.
-inability to bathe leisure. However needs possible.
and groom self there are some -safely executes  Assist in self-grooming  Patients may had -unmet if client will not
independently. that might have self-care hard time or it takes able to demonstrate
difficulties in activities to longer for him to lifestyle changes and
Nursing performing self- utmost capability. dress or groom safely executes self-
diagnosis: care example is himself. care activities to utmost
Self-care deficit my patient where  Provide assistive device like  Since patient is capability.
related to he can’t perform urinal. immobilize he is
musculoskeletal some of ADL’s unable to access
impairment. due to the bathroom.
condition he
 have right now.  Encourage to collaborate in  To enhance clients
He may perform treatment of underlying capabilities,
other activities conditions. maximize
but need of rehabilitation
assistance. Self- potential.
care refers to
those activities  Educate family and  This displays caring
an individual significant others to promote and concern but
performs autonomy and to intervene if does not hinder with
independently the patient becomes tired, patient’s efforts to
throughout life to not capable of carrying out attain autonomy.
promote and task, or extremely
maintain aggravated.
personal well-  Inform family members to  Reinstitutes feeling
being. allow the patient perform sel- of independence and
care measures as much as promotes self-
possible. esteem and
improves
rehabilitation
process.
Reference/s:
o Doenges,M., Moorhouse, M., Murr, A. (2017). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (14th edition). ISBN 978-974-
652-308-0
o www.google.com/amp/s/nurseslabs.com/self-care-deficit/%3famp
o www.google.com/amp/s/nurseslabs.com/impaired-physical-mobility/%3famp