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DIAGNOSIS
INFERENCE
EXPECTED OUTCOME After 8 hours of nursing intervention the patient will: -demonstrate techniques that enable resumption of activities. -Maintain position of function and skin integrity as evidenced by absence of contractures, foot drops and decubitus.
NSG. INTERVENTION Independent: -Assess the degree of immobility related previous scale. -Note movement when patient is unaware of observation. -Monitor nerve function of affected body parts.
RATIONALE
EVALUATION
Objective: Inability to purposely move within the physical environment including bed mobility, transfer and ambulation. Limited range of motion. inability to move independently Decreased muscle strength. Functional level is 2- requires help from another
Impaired physical mobility related to neuromuscular impairment as manifested by inability to move independently and limited range of motion.
After 4 hours of nursing intervention the patient was able to: -demonstrate techniques that enable resumption of activities. -Maintain position of function and skin integrity as evidenced by absence of contractures, foot drops and decubitus
-Maintain adequate exercise program, using isometric or isotonic exercise and assistive ROM. -Place pillows or foot board at the soles of the foot.
-prevent venous stasis and maintain joint mobility, good body alignment.
-to improve
person for assistance when moving. -teach patient about the safety measure as individually indicated.
circulation