ASSESSMENT NURSING DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective airway Due to neuromuscular Short Term:  Monitor respiratory  To ascertain the Short Term:
“nahihirapan ako clearance related to impairment will affect status and ability to respiratory status of the
lumunok at neuromuscular the muscles and direct to After 4 hours of nursing cough and deep breathe patient and to provide After 4 hours of nursing
huminga, impairment as nervous system control interventions, the adequately. information related to intervention the patient
nabibilaukan din evidenced by which can cause varying patient will be able other systems verbalized in decrease of
ako madalas” as difficulty in degrees of skeletal express decrease in  Monitor vital signs  To note changes and difficulty in swallowing and
verbalized by the swallowing, muscle weakness difficulty in swallowing possible signs of was ventilated to relieve
patient breathing, and and be ventilated complication aspiration.
aspiration  Auscultate breath sounds  To evaluate aspiration
Objective:  Determine the food  To incorporate as
VS: Long Term: preference of the patient possible and enhance
T – 36.5 C intake Long Term:
P – 76bpm After 2 days of nursing  Massage the sides of  To stimulate swallowing
R – 13bpm interventions, the trachea and neck gently After 2 days of nursing
BP – 140/80 patient will be able to  Monitor the patients  An O2sat of less than intervention, the patient
maintain stable pulse oximetry 92% may detect hypoxia was able to maintain stable
(+) difficulty in respiratory status and need for respiratory status with a
swallowing supplemental oxygen 16bpm respiratory rate and
(+) difficulty in  Encourage deep  Increases oxygen normal breath sounds by
breathing breathing exercise and delivery to the body doing deep breathing
administer oxygen if exercise and oxygen
needed therapy
 ASSESSMENT NURSING DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION
Subjective: Impaired physical Due to neuromuscular Short Term:  Assess patient's ability to  Restricted movement Short Term:
“nanghihina ang mobility related to impairment will affect perform ADLs effectively affects the ability to
kalamnan ko at reduced the muscles and direct to After 4 hours of nursing and safely on a daily basis perform most ADLs. After 4 hours of nursing
hindi na ako neuromuscular nervous system control interventions, the Safety with ambulation interventions, the patient
nakakagawa ng function as which can cause varying patient will be able to is an important concern was able to demonstrate
mga trabaho” as evidenced by degrees of skeletal demonstrate measures  Assess for developing  Bed rest or immobility measures to increase
verbalized by the decrease in muscle muscle weakness to increase mobility thrombophlebitis promotes clot formation mobility by performing
patient endurance, strength, and perform activities  Evaluate need for  Proper use of ROM exercises and perform
and control independently assistive devices wheelchairs, canes, activities independently
Objective: transfer bars, and other with use of assistive devices
VS: assistance can promote
T – 36.6 C Long Term: activity and reduce
P – 80bpm danger of falls Long Term:
R -16bpm After 2 days of nursing  Encourage appropriate  Mobility aids can
BP – 110/80 interventions, the use of assistive devices in increase level of After 2 days of nursing
patient will be free the home setting mobility interventions, the patient
Muscle weakness from immobility  Allow patient to perform  Healthcare workers will be free from immobility
Altered ADL complications and use tasks at his or her own often in a hurry and do complications as evidence
Altered mobility safety measures rate. Do not rush patient. more for patients than by free of thrombophlebitis,
Encourage independent needed, thereby slowing and use safety measures
activity as able and safe patient's recovery and with use of assistive devices
reducing his or her self-
esteem
 Perform passive or active  To promote increased
assistive ROM exercises venous return, prevent
to all extremities stiffness, and maintain
muscle strength and
endurance
 Antispasmodic
  Administer medications medications may reduce
as appropriate muscle spasms or
spasticity that interfere
with mobility.

ASSESSMENT NURSING DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for Injury related Due to neuromuscular Short Term:  Assess patient for degree  Increases awareness of Short Term:
“nahihirapan ako to impaired sensory impairment will affect of visual impairment the problem, and
makakita dahil function secondary the muscles and direct to After 2 hours of nursing  Ascertain knowledge of identifies severity to After 2 hours of nursing
nagdodoble ang to diplopia as nervous system control interventions, the safety needs/ injury allow for the interventions, the patient
paningin ko ” as evidence by patient which can cause varying patient will be able to prevention and establishment of a plan was able to identify factors
verbalized by the reporting he is seeing degrees of skeletal verbalize motivation of care that increase risk for injury
patient double. muscle weakness understanding of  Ensure the room  To prevent injury in
individual factors that environment is safe with different settings
Objective: contribute to possibility adequate lighting and  Provides a safe Long Term:
VS: of injury furniture moved toward environment to reduce
T – 36 C the walls the potential for injury After 2 days of nursing
P – 120bpm  Assess client’s mucsle  To identify risk for falls interventions, the was free
R – 15bpm Long Term: strength, gross, and fine  These techniques help from injury using safety
BP – 110/80 motor coordination enhance visual measures such as using
After 2 days of nursing  Instruct patient regarding discrimination and handrails
(+)misalignment interventions, the safe lighting reduce the potential for
of the eye patient will be able to  Train patient on safe injury
(+) grasping wrong protect self and be free ambulation  Teach ambulation safely
direction from injuries including adding safety
features such as
bathroom handrails at a
patient home