Cues Nursing Diagnosis Inference Objectives Intervention Rationale evaluation

Subjective: Activity Blunt Injury Short Term Goal: >Perform active or >These exercises Short term:
“Hindi ako Intolerance ↓ After 4 hours of nursing passive ROM foster muscle After 4 hours of
makalakad dahil dito related to Injury to phalanges intervention the patient exercises to all strength and tone, nursing
sa paa ko” as impaired physical ↓ will: extremities every 2- maintain joint intervention, goal
verbalized by the mobility as Fracture  Identify negative 4 hours. mobility, and is met as
patient. evidenced by ↓ factors affecting prevent evidenced by
fracture on the Bleeding from activity tolerance contractures. verbalizing the
Objective: phalanges of the damaged ends of and eliminate or >Turn and negative factors
 With left foot. bone and from reduce their reposition the >turning and affecting activity
internal surrounding tissue effects when patient every 2 hrs. repositioning tolerance and a
fixator on ↓ possible. establish a turning prevents skin decreased in
the Stimulates  Use identified schedule for the breakdown and physiological signs
phalanges of inflammatory techniques to dependent patient. improves breathing. with the following
the left foot response enhance activity Post schedule at vital signs:
 With cast ↓ tolerance. bedside and T: 36.2˚C
 VS as Increase capillary  Demonstrate a monitor frequency. PR: 75bpm
follows permeability decrease in > Maintain proper >To avoid RR: 20cpm
T: 36.2 ˚C ↓ physiological body alignment at contractures and BP: 120/80 mmHg
PR: 79 bpm Fluid/cellular signs of all times maintain optimal
RR: 25 cpm exudation intolerance. musculoskeletal Long term:
BP: 120/100 ↓ balance and After 4 days of
mmHg Edema Long Term Goal: >Encourage active physiologic nursing
↓ After 4 days of nursing exercise. Provide a function. intervention, goal
Pain intervention the patient trapeze or other >Such devices is met as
↓ will : assistive device simplify moving and evidenced by
Impaired function  Participate whenever possible. turning for many regaining the
willingly in patients and also patient’s previous
necessary/desire allow them to range of motion in
d activities >Teach isometric strengthen some the leg and
 Report exercises upper-body demonstrates
measurable muscles. proper exercises
increase in for the lower
 activity tolerance > to allow patient extremities. He
 Demonstrates >have patient maintain or increase
and verbalizes perform self care muscle tone and
proper exercise of activities. Begin joint mobility
the lower slowly and increase
extremities and daily as tolerated. >activities will help
can perform >provide emotional patient regain help
activities of daily support and
living with encouragement
minimal >to help improve
assistance. patient’s self-
>involve patient in concept and
care-related motivation to
planning and perform activities of
decision making daily living
>monitor >to improve
physiologic compliance
responses to
increased activity
level, including >to ensure they
respirations, heart return to normal
rate and rhythm, within a few
and blood pressure minutes after
>teach caregivers to exercising
assist patient with
self-care activities in
a way that
maximizes patient’s >this enables
potential caregivers to
participate in
patient’s care and
>place needed also encourages
objects within reach them to support
patient’s
>explain the independence.
importance of
following prescribed
medical and >to encourage
physical therapy independence
regimens
>when the patient
understands his
condition improves,
his compliance
increases.