NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: “Nanghihina ako, pakiramdam ko hindi ko kayang gumalaw” (I feel weak, I can’t move) as verbalized by the patient. OBJECTIVE: ♦ Paralysis. ♦ Muscle

atrophy.

♦ V/S taken as follows:

T: 37.1 P: 89 R: 20 BP: 110/90

♦ Impaired physical mobility related to neuro-mascular impairment.

♦ Kyphosis (Greek - kyphos, a hump), in general terms, is a curvature of the upper spine. It can be either the result of bad posture or a structural anomaly in the spine. In the sense of a deformity, it is the pathological curving of the spine, where parts of the spinal column lose some or all of their lordotic profile. This causes a bowing of the back, seen as a slouching posture. Symptoms of kyphosis, that may be present or not, depending on the type and extent of the deformity,

♦ After 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.

INDEPENDENT:

♦ Continually assess motor function by requesting patient to perform certain actions like shrugging shoulders, spreading fingers.

♦ Assist with full range of motion exercises in all extremities and joints using slow, smooth movements.

♦ Position arms at 90-degree angle at regular intervals.

♦ Elevate lower

extremities at intervals when in chair or raise foot or bed when permitted in individual situation.

♦ Evaluates status of individual situation, affecting type and choice of interventions.

♦ Enhances circulation, restores muscle tone and joint mobility.

♦ Prevents frozen shoulder contractures.

♦ Loss of vascular

tone and muscle action results in pooling of blood and venous stasis in the lower abdomen and lower extremities, with increased risk of hypotension and thrombus formation.

♦ After 8 hours of nursing interventions, the patient was able to demonstrate techniques or behaviors that enable resumption of activity.

include mild back pain, fatigue, appearance of round back and breathing difficulties. Severe cases can cause great discomfort and even lead to death.

♦ Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance or ability.

♦ Encourage use of relaxation techniques.

♦ Inspect skin daily.

Observe for pressure areas and provide meticulous care.

COLLABORATIVE:

♦ Consult with physical therapist.

♦ Prevents fatigue, allowing opportunity for maximal efforts or participation by the patient.

♦ Reduces muscle tension, may limit pain of muscle spasm.

♦ Altered

circulation, loss of sensation, and paralysis potentiate pressure sore formation.

♦ Helpful in planning and implementing individualized exercise program and identifying assistive devices to maintain function, enhance mobility and independence.