ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Nursing Scientific Goals and Nursing Order Rationale

Diagnosis Rationale Desired Outcome

Subjective: Impaired Osteomyelitis tends .With continuous Assess patient’s • Restricted movement After 4 hours of rendering nursing
physical to occlude local nursing ability to perform affects the ability to interventions the Goal was
“Hindi ko mobility related blood vessels, interventions for 4 ADLs effectively perform most ADLs. partially met as manifested by:
maigalaw ang to musculo- which causes bone hours given, the and safely on a Safety with ambulation
kaliwang paa ko,” skeletal necrosis and local patient will be able daily basis. is an important 
as verbalized by impairment as spread of infection. to prevent concern. Limited range of motion but
the patient. evidenced by: Infection may complications Suggested Code able to do passive range of
expand through the related to for Functional motion like moving the toes of
Objective:  bone cortex and immobility as Level feet
Limited spread under the evidenced by Classification
 Limited range of periosteum, with 0 Completely  Muscle strength not
range of motion formation of  No independent progressively decreasing.
motion (ROM) subcutaneous limitation 1 Requires use of
(ROM) abscesses that may in equipment or device
 Decreas drain spontaneously movement 2 Requires help
 Decrease e in muscle through the skin.  Increase from another person The patient verbalizes,”
in muscle strength This inflammatory muscle for assistance, Naigagalw ko naman kahit konti
strength especially reaction causes strength supervision, or yung daliri ko sa paa.”
specially on on the left impairs mobility of teaching
the left leg leg patient because of 3 Requires help
compression of The patient will from another person
nerve endings verbalize: and equipment or
initiating pain “ Medyo device
perception. nagagalaw ko na 4 Is dependent,
ang mga daliri ko does not participate
sa paa.” in activity

Encourage and The longer the patient

facilitate early remains immobile the
ambulation and greater the level of
other ADLs when debilitation that will
possible. Assist with occur.
each initial change:
dangling, sitting in
chair, ambulation.

* Facilitate transfer
training by using • Ensure the safety of
appropriate the patient
assistance of
persons or devices
when transferring
patients to bed,
chair, or stretcher.

* Encourage • Mobility aids can

appropriate use of increase level of
assistive devices in mobility.
the home setting.

* Provide positive • . Patients may be

reinforcement reluctant to move or
during activity initiate new activity
due to a fear of
inability to perform
task.

* Allow patient to • Enable the patient to

perform tasks at his maintain self esteem
or her own rate. Do and gain optimal
not rush patient. cooperation during the
activity.

• Hospital workers and

* Encourage family caregivers are
independent activity often in a hurry and do
as able and safe. more for patients than
needed, thereby
slowing the patient’s
 recovery and reducing
his or her self-esteem.

* Keep side rails up • This promotes a safe

and bed in low environment.
position.

* Turn and position • This optimizes

every 2 hours or as circulation to all
needed. tissues and relieves
pressure.

* Maintain limbs in
functional alignment • This prevent excessive
(e.g., with pillows, flexion or tightness.
sandbags, wedges, or
prefabricated splints).

* Perform passive or • Exercise promotes

active assistive ROM
exercises to all
extremities.
increased venous
return, prevents
stiffness, and maintains
muscle strength and
endurance.

• This prevents tissue

* Use prophylactic breakdown.
antipressure devices as
appropriate. Clean, dry,
and moisturize skin as
needed.

* Encourage coughing • These prevent buildup

and deep-breathing of secretions.
exercises.

* Encourage liquid • Liquids optimize

intake of 2000 to 3000 hydration status.
ml/day unless
contraindicated.
• Proper nutrition is
required to maintain
* Initiate supplemental adequate energy level.
high-protein feedings as
appropriate.

• Prevents additional
energy consumption.
* Keep personal articles
within reach.

• Help patient or
* Explain progressive caregivers to establish
activity to patient. reasonable and
obtainable goals.
* Instruct patient or
• Ensure effectivity of
caregivers regarding
the interventions given.
hazards of immobility.
Emphasize importance
of measures such as
position change, ROM,
coughing, and exercises.

* Reinforce principles of • Helps prevent

progressive exercise, contractures, atrophy
emphasizing that joints and ulcer formation.
are to be exercised to the
point of pain, not
beyond. "No pain, no
gain" is not always true!
• A safe environment is
* Instruct patient/family a prerequisite to
regarding need to make improved mobility.
home environment safe.