Republic of the Philippines

Bicol University Polangui Campus

NURSING AND HEALTH SCIENCES DEPARTMENT
S.Y 2018-2019

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT:
OBJECTIVE: After 8 hours of nursing 1. Change positions at  Reduces risk of After 8 hours of nursing
+ impaired coordination “Impaired Physical intervention, the patient least every 2 hours tissue ischemia and intervention, the patient
+ decreased muscle Mobility r/t perceptual or will (supine, side lying) injury. Affected was able to maintain or
strength cognitive impairment as and possibly more side has poorer increase strength and
+ poor motor control evidenced by impaired often if placed on circulation and function of affected or
coordination and decreased affected side. reduced sensation compensatory body part.
muscle strength and and is more
control” predisposed to skin
breakdown and
pressure ulcers.
2. Place pillow under  Prevents adduction
axilla to abduct arm. of shoulder and
flexion of elbow.
3. Elevate arm and hand.  Promotes venous
return and helps
prevent edema
4. Place knee and hip in formation.
extended position.  Maintains
5. Observe affected side functional position.
for color, edema, or  Edematous tissue is
other signs of more easily
compromised traumatized and
circulation. heals more slowly.
 Minimizes muscle
atrophy, promotes
6. Begin active or passive circulation, and
ROM to all extremities helps prevent
(including contractures.
splinted) on admission.
Encourage exercises,
such as
quadriceps or gluteal
exercise, squeezing
rubber ball, and
extension of fingers  Aids in retraining
and legs and feet. neuronal pathways,
7. Assist client to develop enhancing
sitting balance (such as proprioception
raise head of and motor
bed; assist to sit on response.
edge of bed, having
client use the
strong arm to support
body weight and strong
leg to move
affected leg; increase
sitting time) and
standing balance—
put flat walking shoes
on client, support
client’s lower back
with hands while
positioning own knees
outside client’s
knees, and assist in
using parallel bars and
walker.
8. Set goals with
client/significant other
(SO) for increasing
 participation  Promotes sense of
in activities, exercise, expectation of
and position changes. progress and
improvement,
COLLABORATIVE and provides some
1) Consult with physical sense of control
therapist regarding and independence.
active, resistive
exercises and client
ambulation.  Individualized
program can be
developed to meet
particular
needs and deal with
2) Administer muscle deficits in balance,
relaxants and coordination, and
antispasmodics as strength.
indicated,  May be required to
such as baclofen relieve spasticity in
(Lioresal) and affected
dantrolene (Dantrium). extremities.