Patient D.F. ; 75/F Adm. Diagnosis: Complicated UTI HFREF sec.

REF sec. to CAD s/p PCI T2DM (2019) Ischemic Cardiomyopathy

Chief complaint: chills

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired After 8 hours of nursing 1. Assess 1. To initiate Goal met. After 8 hours of
“Nakakalakad at physical interventions, the client will degree of proper care & nursing interventions, the
nakakagalaw ako mobility of the be able to: immobility be able to client was able to:
pero kailangan ko ng upper and 1. Demonstrate some assist client in 1. Demonstrate some
alalay” as verbalized lower techniques/behaviors some of her techniques/behaviors
by the client. extremities r/t that enables ADLs that enables
neuromuscular resumption of 2. Maintain 2. To refocus resumption of
Objective: skeletal activities stimulating client’s activities
 Functional impairment 2. Participate in doing environment attention & 2. Participate in doing
level aeb limitation ADLs & desired such as: aid in ADLs & desired
classification: in moving, activities as tolerated a. Listening to reducing activities as tolerated
3 (requires decreased 3. Maintain position of the radio social 3. Maintain position of
help from muscle function & skin b. Watching TV isolation function & skin
another strength and integrity c. Reading integrity
person & needs of newspaper
equipment assistance d. Conversing
device) when turning with visitors
 Muscle and moving 3. Assist client 3. To increase
strength with blood flow to
score of 2/5 active/passive muscles and
(muscle can ROM bones in order
contract but exercises to maintain
can’t move joint mobility
body part 4. Reposition 4. To
fully against client every 2 prevent/reduce
gravity) hours and incidence of
 (+) Weakness encourage to skin &
& limitation do DBE
 in motion of respiratory
body parts complications
 (+) Limited
ROM
 Needs
assistance
when moving
and turning