NURSING CARE PLAN FORMAT

Name:_________________________________ Medical Diagnosis: __________________________________ Date:

_________________
Nursing Assessment Nursing Interventions
Subjective Objective Interventions Rationale
Patient manifested Paralysis 1. Consider the 10 rights of a patient. to ensure the ethical treatment of
by loss of movement Muscle atrophy persons receiving medical or other
professional health care services.
Irritability Continually asses motor function (as spinal shock or Evaluates status of individual situation (motor-sensory
edema resolves) by requesting patient to perform impairment may be mixed and/ or not clear) for a
certain actions. specific level of injury, affecting type and choice of
intervention
3.
5. Provide means to summon help. 7. Enables patient to have sense of control, and
6. reduces fear of being left alone.

Nursing Diagnosis 9. Administer muscle relaxants or antispasticity as May be useful in limiting or reducing pain associated
Impaired physical mobility prescribed. with spasticity
Problem
11. Monitor vital sign To obtain baseline data.
Related to neuromuscular
Related
impairment
factor
13. Assist in range of motion exercises on all 15. Enhances circulation, restores or maintains
As evidenced by paralysis on the extremities and joints, using slow, smooth muscle tone and joint mobility, and prevent
lower extremity movements. disuse contractures and muscle atrophy.
14.
Defining
 Reposition periodically even when sitting in chair. 1. Reduces pressure areas, promotes peripheral
characteri Teach patient how to use weight-shifting circulation.
stics techniques.

17.
Nursing Inference 3. Inspect the skin daily. Observe for pressure 5. Altered circulation, loss of sensation, and
Spinal cord injuries may result from areas and provide meticulous skin care. paralysis potentiate pressure sore formation.
4.
damage to the vertebrae, ligaments or 7. Plan activities to provide uninterrupted rest 9. Prevents fatigue, allowing opportunity for
periods. Encourage involvement within maximal efforts or participations by patient.
disks of the spinal column or to the spinal
individual tolerance or ability.
cord itself. when the arms, hands, trunk, 8.
legs and pelvic organs are all affected by 10.
your spinal cord injury due to trauma.
Therefore, there is impaired physical
impairment due to neuromuscular
impairment as evidenced by paralysis
After 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.
Nursing Plan/Goal

After 8 hours of nursing interventions, the goal is partially met. The patient was able to demonstrate techniques or behaviors that enable
Nursing resumption of activity.
Evaluation
Prof. AltroyVanAgtang