ASESSMENT

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

Subjective: Di ako masyado makagalaw. As verbalized by the patient

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.

Slow tumour growth in spinal cord

Provides as a baseline data

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

Pressure build up in the spinal cord

-to further assess which part is in pain

Injury to white matter and grey matter

-to assess if the neurologic function o f that part is functioning

Malfunction of transmission pathway

-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.

Leading to physical immobility

-to prevent foot drop

-Provide skin care.

-to improve

person for assistance when moving. -teach patient about the safety measure as individually indicated.

circulation

-To prevent accidents.