CUes Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective:
Lisod kayo
ilihok tungod ani
akong tiil as
verbalized by the
patient




Objective:
Slowed
movement
Difficulty in
turning
Facial
grimace
when
trying to
move side
to side








Impaired physical
mobility
related to
neuromuscular
involvement(muscle
weakness and
numbness) as
manifested by
slowed movement,
difficulty in turning
and facial grimace
when trying to
move on side to side.


After 8 hours of
nursing care the
patient will be
able to:
Increases
physical
activity
Meets
mutually
defined goals
of increased
mobility
Verbalizes
feeling of
increased
strength and
ability to
move
Demonstrates
use of
adaptive
equipment
(e.g.,
wheelchairs,
walkers) to
increase
mobility


1. Screen for
mobility skills in the
following order:
(1) bed mobility;
(2) supported and
unsupported sitting;
(3) transition
movements such as
sit to stand, sitting
down, and
transfers; and
(4) standing and
walking activities.
Use a physical
activity tool if
available to evaluate
mobility.












Screening
mobility skills
helps provide
baselines of
performance
that can guide
mobility-
enhancement
programming
and allows
nursing staff to
integrate
movement and
practice
opportunities
into daily
routines and
regular and
customary
care. There are
many tools
available to
measure
physical
activity;
selection of the
appropriate


GOAL
PARTIALLY
MET!

After 8 hours
of nursing
care the
patient was
able to:
Increases
physical
activity
Meets
mutually
defined
goals of
increased
mobility
Verbalizes
feeling of
increased
strength
and ability
to move







2. Observe client for
cause
of impaired mobility.
Determine whether
cause is physical or
psychological





4. Before activity
observe for and, if
possible, treat pain.
Ensure that client is
not over sedated.



5. Consult with
physical therapist
for further
evaluation, strength
training, gait
training, and
development of a
tool depends
on the setting
and situation

Some clients
choose not to
move because
of
psychological
factors such as
an inability to
cope or
depression.


Pain limits
mobility and is
often
exacerbated
by movement.



Techniques
such as gait
training,
strength
training, and
exercise to
improve
mobility plan.





6. Obtain any
assistive devices
needed for activity,
such as walking
belts, walkers,
canes, crutches, or
wheelchairs, before
the activity begins.

7. If client is
immobile, perform
passive range of
motion (ROM)
exercises at least
twice a day unless
contraindicated;
repeat each
maneuver three
times.
balance and
coordination
can be very
helpful for
rehabilitating
clients

Assistive
devices can
help increase
mobility.





Passive ROM
exercises help
maintain joint
mobility,
prevent
contractures
and
deformities,
increase
circulation,
and promote a
feeling of
comfort and
well-being
Cues Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective:
No verbal cues"





Ineffective
Breathing Pattern
secondary to
Pulmonary
Tuberculosis with
pneumonia

















Cues Nursing
Diagnosis
Planning Nursing
Intervention
Rationale Evaluation

Subjective:
no verbal cues






Objectives:
Use of
accessory
muscle
Dyspnea
Restlessness


Ineffective
Breathing
Pattern
secondary to
pulmonary
tuberculosis
with
pneumonia

After 8 hours
of nursing care
the patient will
be able to:

-Re-establish
and maintain
effective
respiratory
pattern via
oxygen
administration
thru nasal
cannula without
the use of
accessory
muscles and
other signs
of hypoxia


Monitor vital
signs


















Assess
respiratory
rate, rhythm
and depth



These signs,
which should
be looked at in
total, are
checked to
monitor
functions
of the body.
The signs
reflect
changes in
function that
otherwise
might not be
observed


Respiratory
rate and
rhythm
changes are
early warning
signs
of impending

After 8 hours
of nursing care
the patient
was able to:ss

-Re-establish
and maintain
effective
respiratory
pattern via
oxygen
administration
thru nasal
cannula without
the use of
accessory
muscles and
other signs
of hypoxia







Assess for
pain/discomfo
rt




Administer
O2
regulated at 2 l/pm
via nasal cannula as
ordered and
administer
prescribed
respiratory
medications

respiratory
difficulties

That may
restrict
respiratory
effort


For
management
of underlying
pulmonary
condition and
respiratory
distress