Assessment

SUBJECTIVE:

Diagnosis
Impaired physical mobility related to Neuromuscular Skeletal Impairment evidenced by reluctance to attempt movement; limited ROM and decrease muscle strength

Analysis
Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis).The incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the

Planning
During the patients stay at the hospital she will be able to: > Regain/maintain mobility at the highest possible level. > Maintain position of function. > Increase strength/function of affected and compensatory body parts > Demonstrate techniques that enable resumption of activities.

Intervention
>Assess degree of immobility produced by injury/treatment and note patients perception of immobility. > Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. > Assist with/encourage self-care activities (e.g., bathing, shaving). > Reposition periodically and encourage coughing/deepbreathing exercises. > Increase the amount of roughage/fiber in the diet. Limit gas-forming foods. > Note emotional/behavioral responses to problems of immobility. > Encourage

Rationale
> requiring information/interventions to promote progress toward wellness.

Evaluation
After Nursing intervention: > Regain/maintain mobility at the highest possible level. > Maintain position of function. > Increase strength/function of affected and compensatory body parts > Demonstrate techniques that enable resumption of activities. Nursing objective was met

Nasasakitan akong maghiro as verbalized by the patient OBJECTIVE: >confined to bed rest >limited range of motion >difficulty turning side >slowed movement >paresthesia noted at the lower extremities >functional level scale: 2 (requires help from another person for assistance, supervision or teaching

> Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; > Improves muscle strength and circulation, > Prevents/reduces incidence of skin and respiratory complications (e.g., decubitus, atelectasis, pneumonia). > Adding bulk to stool helps prevent constipation. > Feelings of frustration or powerlessness may impede attainment of goals. > Enhances self-concept and sense of

home environment.

participation in selfcare; occupational, diversional, or recreational activities. > Consult with physical or occupational therapist, as indicated

independence.

> Refer to psychiatric clinical nurse specialist/therapist as indicated.

> to develop individual exercise and mobility program, and identify appropriate mobility devices. > Patient/SO may require more intensive treatment to deal with reality of current condition/prognosis, prolonged immobility, perceived loss of control.

PATIENT DATA:
Name: Ms. X Age: 27 Address: Bagacay, Labo, Camarines Sur Religion: Roman Catholic Nationality: Filipino DOA: February 1, 2013 Diagnosis: To consider Demyelinating Disease VS Potts Disease

History of Present Illness

Ms. X condition started 2 months prior to admission and patient had onset of Body Malaise, Immobility of lower extremities with Paresthesia , was admitted at Camarines Norte Provincial Hospital, Xray, ECG, CBC test done, was given meds and efforted temporarily few hour after the admission, patient have body malaise prompted consult hence admitted.