ASESSMENT
DIAGNOSIS
INFERENCE
EXPECTED OUTCOME After 8 hours of nursing intervention the patient will: -demonstrate techniques that enable resumption of activities. -Maintain position of function and skin integrity as evidenced by absence of contractures, foot drops and decubitus.
NSG. INTERVENTION Independent: -Assess the degree of immobility related previous scale. -Note movement when patient is unaware of observation. -Monitor nerve function of affected body parts.
RATIONALE
EVALUATION
Subjective: Di ako masyado makagalaw. As verbalized by the patient
Objective: Inability to purposely move within the physical environment including bed mobility, transfer and ambulation. Limited range of motion. inability to move independently Decreased muscle strength. Functional level is 2- requires help from another
Impaired physical mobility related to neuromuscular impairment as manifested by inability to move independently and limited range of motion.
Slow tumour growth in spinal cord
Provides as a baseline data
After 4 hours of nursing intervention the patient was able to: -demonstrate techniques that enable resumption of activities. -Maintain position of function and skin integrity as evidenced by absence of contractures, foot drops and decubitus
Pressure build up in the spinal cord
-to further assess which part is in pain
Injury to white matter and grey matter
-to assess if the neurologic function o f that part is functioning
Malfunction of transmission pathway
-Maintain adequate exercise program, using isometric or isotonic exercise and assistive ROM. -Place pillows or foot board at the soles of the foot.
-prevent venous stasis and maintain joint mobility, good body alignment.
Leading to physical immobility
-to prevent foot drop
-Provide skin care.
-to improve
person for assistance when moving. -teach patient about the safety measure as individually indicated.
circulation
-To prevent accidents.