Professional Documents
Culture Documents
Date
Diagnosis
Objectives
Interventions
Impaired
Physical
nursing
Unable to move
to
on his own
Neuromuscular
Limited range of
involvement:
total
paralysis
as
evidenced
by
evidenced by the
inability
to
lack of footdrop
311
Needs
motion
Decreased
muscle
strength/coordi
nation
Vital Signs
o T: 36.0C
o P: 82 bpm
o RR: 22 cpm
o BP: 183/110
E
X
E
purposefully
move
ability / extent of
strengths,
After 8 hours of
initial damage by
weaknesses and
nursing
way of regular,
can provide
interventions,
to:
classified by scale
information
of 0-4.
through the
not
the
the
optimal position
contracture.
if possible more
physical
strength
environment
function of the
and
affected
S
E
decreased
muscle strength
control
Evaluation
Maintain
body
Rationale
To identify
and
often if placed in a
compromised
position.
recovery.
2 Lowering the risk
of trauma /
ischemia area
damaged tissue is
more bad
circulation and
minimize pressure
or
sores.
3 Minimizing
compensation.
3 Perform the
exercise of active
able
maintain
to
the
optimal position
of function as
evidenced
by
the
of
lack
footdrop
contracture.
decrease of
sensation and
body
part
muscle atrophy
helps increase
able
maintain
to
/
improve
strength
and
function of the
of motion.
T
E
4 Prop extremities in
functional position;
use footboard
circulation
affected
mensegah
part
contractures.
Prevents
compensation.
contractures and
footdrop and
facilitates use
flaccid paralysis.
when function
Maintain neutral
returns. Flaccid
position of head.
paralysis may
interfere with
ability to support
head, whereas
spastic paralysis
may lead to
deviation of head
to one side.
Prevents adduction
of shoulder and
flexion of elbow.
6 Hard cones
decrease the
thumb opposed.
stimulation of
body
or
finger flexion,
maintaining finger
7 Encourage patient
and thumb in a
to assist with
functional
movement and
exercises using
position.
May respond as if
unaffected
affected side is no
extremity to
and needs
weaker side.
encouragement
and active training
to reincorporate
it as a part of own
body.
8 Observe affected
Edematous
tissue is more
edema, or other
easily
signs of
traumatized
compromised
circulation.
slowly.
9
9 Inspect skin
Pressure points
over bony
regularly,
prominences
particularly over
bony prominences.
for decreased
perfusion.
Circulatory
stimulation and
sheepskin pads as
padding help
necessary.
prevent skin
breakdown and
decubitus
development.
10 Begin active or
passive ROM to all
extremities
(including splinted)
on admission.
Encourage
exercises such as
quadriceps/gluteal
exercise, squeezing
rubber ball,
extension of fingers
10
11 Minimizes
muscle atrophy,
promotes
circulation,
helps prevent
contractures.
Reduces risk of
hypercalciuria
and
osteoporosis if
and legs/feet
underlying
problem is
hemorrhage.
Note:
Excessive
stimulation can
predispose to
rebleeding.