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    Impaired Physical Mobility R/T Neuromuscular Impairment

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    jisoo
    Monitor for side effects of medication and report to physician as needed. Independent: 8. Monitor for side effects of medication and report to physician as needed. Goal: Patient will maintain mobility and prevent complications related to immobilization with nursing interventions within 3 hours.

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    Impaired Physical Mobility R/T Neuromuscular Impairment

    Uploaded by

    jisoo
    172 views3 pages
    Monitor for side effects of medication and report to physician as needed. Independent: 8. Monitor for side effects of medication and report to physician as needed. Goal: Patient will maintain mobility and prevent complications related to immobilization with nursing interventions within 3 hours.

    Original Description:

    Nursing care plan

    Original Title

    Impaired physical mobility r/t neuromuscular impairment

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    Monitor for side effects of medication and report to physician as needed. Independent: 8. Monitor for side effects of medication and report to physician as needed. Goal: Patient will maintain mobility and prevent complications related to immobilization with nursing interventions within 3 hours.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    172 views3 pages

    Impaired Physical Mobility R/T Neuromuscular Impairment

    Uploaded by

    jisoo
    Monitor for side effects of medication and report to physician as needed. Independent: 8. Monitor for side effects of medication and report to physician as needed. Goal: Patient will maintain mobility and prevent complications related to immobilization with nursing interventions within 3 hours.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    NURSING GOALS

    NURSING DIAGNOSIS
    WITH POSSIBLE NURSING RATIONALE ( with
    WITH SUBJECTIVE IMPLEMENTATION EVALUATION
    OUTCOME INTERVENTIONS Reference)
    AND OBJECTIVE CUES
    CRITERIA
    Subjective: After 3 hours of nursing Independent: Goal met. After 3 hours
    “Hindi ako makagalaw” (I care and health teaching 1. Continually Evaluates status of individual  Assessed motor of nursing care and
    can’t move) as verbalized by the patient will maintain assess motor situation (motor-sensory function by health teaching the
    the patient. position of function as function by impairment may be mixed and requesting patient patient was able to
    evidenced by absence of requesting or not clear) for a specific level to perform certain maintain position of
    Objective: contractures, foot drop patient to of injury, affecting type and actions (e.g, shrug function as evidenced by
    Diagnostic procedure results = and increase strength of perform choice of interventions shoulders, spread absence of contractures,
    Date:01/22/2019 unaffected/compensator certain actions fingers, foot drop, and increase
     MRI of cervical spine- y body parts (e.g, shrug release/squeeze strength of
    spondylodiskitis at C3- shoulders, examiner’s hands unaffected/compensator
    C5 with subluxation at spread fingers, Enhances circulation, y body parts.
    C3-C4 and extensive release/squeez restores/maintains muscle  Performed/assiste
    paravertebral e examiner’s tone and joint mobility and d with full ROM
    collective from C2 to hands prevents disuse contractures exercises on all
    T1. Spinal cord 2. Perform/assist and muscle atrophy extremities and
    compression at C3 to with full ROM joints, using slow
    C4 level. exercises on all smooth
     Cervical Spine APL- extremities and movements.
    Posterior joints, using Hyperextend hips
    dislocation/retropulsio slow smooth Prevents frozen shoulder periodically
    n of C5 in relation to movements. contractures
    C4 (Grade 4 Hyperextend  Positioned the
    Retrolisthesis) hips patient’s arms
    periodically Prevents foot drop and at 90 degree
    Nursing diagnosis: 3. Position arms external rotation of hips. at regular
    Impaired physical mobility r/t at 90 degree at intervals
    neuromuscular impairment regular
    intervals  Maintained
    ankles at 90
    degree with
    4. Maintain Altered circulation, loss of
    footboard
    ankles at 90 sensation, and paralysis
    Place
    degree with potentiate pressure sore trochanter rolls
    footboard. formation. along thighs
    Place when in bed
    trochanter rolls
    along thighs In a high percentage of clients  Assessed the
    when in bed with cervical cord injury, skin of the
    5. Assess skin thrombi develop because of patient daily,
    daily. Observe altered peripheral circulation, observe for
    for pressure immobilization, and flaccid pressure areas
    areas and paralysis. Greatest during 2 and provided
    meticulous
    provide weeks but persist throughout
    skin care.
    meticulous skin life span
    care
     Assessed for
    6. Assess for redness,
    redness, swelling/muscl
    swelling/muscl e tension of
    e tension of Development of pulmonary calf tissues.
    calf tissues. emboli may be silent because Record calf nd
    Record calf and pain is altered and DVT is not thigh
    thigh easily recognized measurements
    measurements as indicated.
    as indicated
     Investigated
    sudden onset
    of dyspnea,
    May be useful for reducing cyanosis and
    7. Investigate pain associated with spasticity. other signs of
    sudden onset Note: Baclofen may be respiratory
    of dyspnea, delivered via implanted distress.
    cyanosis, and intrathecal pump on a long
    other signs of term basis as appropriate  Administered
    resp. distress. Baclofen (Lioresal)
    Reference: Nursing Care 10 mg/tab TID as
    Collaborative: Plans: Diagnoses, Intervention ordered by the
    Administer medication s, and Outcomes, 8th Edition physician.
    by Meg Gulanick
    as indicated Baclofen
    (Lioresal) 10 mg/tab
    TID as ordered by the
    physician.

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