Emilio Aguinaldo College College of Nursing and Midwifery

ASSESSMENT MINI PATHOPHYSIOLOGY

NURSING DIAGNOSIS

GOAL/PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“Namamanhid yung buong braso ko.”

Objective:-(+) pain-Weak Pulse-Delayed capillary refill (5 seconds)

Fall from 15 ft high and landed with his

left shoulder.

Shoulder joint damage

Local swelling and tissue hypertrophy

around the shoulder.

Ulnar nerve compression

Alteration of sensory perception related to limited ability to perform motor skills.

After 8 hours of nursing interventions the patient will be able to identify awareness of sensory perception.

-Checked the color of the skin of the affected arm.

-Measured capillary refill.

-Monitored vital signs.

-Teached the patient about passive exercises.

-Encouraged patient to use relaxation techniques (deep breathing exercises)

-To check for the circulation.

-To check for the circulation in the affected area.-To have baseline data.

-To enhance circulation in the affected area.

-To decrease tension level.

Goal Met. After 8 hours of nursing interventions the patient had identified awareness of sensory perception.

Limited body movement

Numbness

-Evaluated sensory awareness: stimulus of dull/sharp

-May indicate decrease peripheral circulation.