NURSING CARE PLAN

POLIOMYELITIS

Name: CASSEY MAE M. CUREG Year & Section: BSN 3 – C

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Impaired physical Short term: 1. Monitor Vital Signs 1. To note changes and for baseline Short term:
Data: mobility related to After 8 hours of comparison. After 8 hours of
“Parang decreased strength nursing 2. Determine the diagnosis that nursing
lantang gulay and endurance intervention the contributes to immobility. 2. These conditions can cause intervention the
ang kanang secondary to patient will physiological and psychological patient is able to
binti ng anak neuromuscular demonstrate 3. Note factors affecting current problems that can seriously demonstrate
ko. Di niya impairment as increased strength situation and potential time impact physical, social, and increased strength
maigalaw ng evidenced by and function of involved. economic well-being. and function of
maayos at inability to affected body affected body part.
parang purposively move part. 4. Evaluate for presence and 3. Identifies potential impairments
nanghihina.” and lower leg degree of pain, listening to and determines types of Long term:
As verbalized paralysis. Long term: client’s description about interventions needed to provide After 1 month of
by the patient’s After 1 month of manner in which pain limits for client’s safety. nursing
mother. nursing mobility intervention the
intervention the 4. To determine if pain management patient is able to:
Objective patient will be 5. Continually assess motor can improve mobility.  Maintain position
Data: able to: function by requesting patient of function as
Age: 3 y/o  Maintain to perform certain actions like 5. Evaluates status of individual evidenced by
Gender: position of shrugging shoulders, spreading situation, affecting type and absence of foot
Female function as fingers. choice of interventions. drop.
Height: 95.3 evidenced by  Perform physical
cm absence of foot 6. Assess the strength to perform 6. This assessment provides data on activity
Weight: 29 lbs. drop. ROM to all joints. extent of any physical problems independently or
 Perform physical and guide therapy. Testing by a within limits of
 Ascending activity 7. Ascertain client’s perception of physical therapist may be needed. disease.
Paralysis independently or activity and exercise needs and  Increase strength
 The patient within limits of impact of current situation. 7. Helps to determine client’s of
is weak disease. Identify cultural beliefs and expectation and beliefs related to unaffected/comp
 Have limited  Increase expectations affecting recovery activity and potential long-term ensatory body
ROM activity strength of or response to long-term effect of current immobility. Also, parts.
 Minimized unaffected/com limitations. identifies barriers that may be  Demonstrate
movement pensatory body addressed. techniques/behav
 Level of parts. 8. Ascertain nutritional status and iors that enable
functional  Demonstrate client’s report or energy level. 8. Deficiencies in nutrients and resumption of
mobility – 2; techniques/beha water, electrolytes, and minerals activity.
Requires viors that enable 9. Determine degree of can negatively affect activity
assistance resumption of immobility in relation to 0 to 4 tolerance.
when activity. scale, noting muscle strength
walking. and tone, joint mobility, 9. Identifies strengths and deficits
cardiovascular status, balance, and may provide information
RR: 26 and endurance. regarding potential for recovery.
PR: 110
BP: 90/60 10. Discuss discrepancies in 10. May be necessary when the client
TEMP: 36.6 movement noted when client is is using avoidance or controlling
unaware of observations and behavior or is not aware of his or
address methods for dealing her own abilities due to anxiety or
with identified problems. fear.

11. Note emotional/behavioral 11. Feelings of frustration or

responses to problems of powerlessness may impede
immobility. attainment of goal.

12. Determine presence of 12. Effects of immobility are rarely

complications related to
immobility.
13. Assist with the treatment of
underlying condition causing
pain and/or dysfunction.
confined to one body system and
can include muscle wasting,
contractures, pressure sores,
constipation, aspiration
pneumonia, thrombotic
phenomena, and weakened

14. Assist or have client reposition
self on a regular schedule as
dictated by individual situation.
15. Perform and encourage regular
skin examination and care.
16. Provide or recommend
pressure-reducing mattress,
such as egg crate, or pressure-
relieving mattress, such as
alternating air pressure, or
water.
17. Encourage adequate intake of
fluids and nutritious foods.
18. Administer medications prior
to activity as needed for pain
relief.
19. Give medications as
appropriate.
20. Collaborate with physical
medicine specialist and
occupational or physical
therapists in providing range-
of-motion exercise (active or
passive), isotonic muscle
contractions, assistive devices,
and activities.
immune system functioning.
13. To maximize the potential for
mobility and function.
14. To reduce pressure on sensitive
areas and to prevent development
of problems with skin integrity.
15. Reduces tissue pressure and aids
in maximizing cellular perfusion to
prevent dermal injury.
16. Promotes well-being and
maximizes energy production.
17. To permit maximal effort and
involvement in activity.
18. Antispasmodic medications may
reduce muscle spasms or
spasticity that interferes with
mobility; analgesics may reduce
pain that impedes movement
19. …
20. To develop individual exercise and
mobility program, to identify
appropriate mobility devices, and
to limit or reduce effects and
complications of immobility.

21. Encourage client’s/SO’s
involvement in decision-making
as much as possible.
22. Involve client and SO in care,
assisting them to learn ways of
managing problems of
immobility.
21. Enhances commit to plan,
optimizing outcomes.
22. May need referral for support and
community services to provide
care, supervision, companionship,
respite services, nutritional and
ADL assistance, adaptive devices
or changes to living environment,
financial assistance, etc.