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I

Date

Nursing Care Plans


Cues

July 19, Objective


2016

Diagnosis

Objectives

Interventions

Impaired

After 8 hours of 1 Assess functional

Physical

nursing

Mobility related interventions,

Unable to move

to

on his own

Neuromuscular

Limited range of

involvement:

total

paralysis

as

of function as 2 Change position at

evidenced

by

evidenced by the

least every 2 hours

inability

to

lack of footdrop

(back, oblique) and

Patient has total


body paralysis

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

patient will be able

way of regular,

can provide

interventions,

to:

classified by scale

information

the patient was

of 0-4.

through the

not

the

the

optimal position

contracture.

if possible more

within Maintain/ improve

physical

strength

environment

function of the

and

affected

S
E

decreased

muscle strength
control

Evaluation

Goal Not Met

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

and passive range

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

The patient was


not

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

during the period of

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

5 Place pillow under


axilla to abduct arm

to one side.
Prevents adduction
of shoulder and

6 Place hard handrolls in the palm

flexion of elbow.
6 Hard cones

with fingers and

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

longer part of body

support and move

and needs

weaker side.

encouragement
and active training
to reincorporate
it as a part of own
body.

8 Observe affected

Edematous

side for color,

tissue is more

edema, or other

easily

signs of

traumatized

compromised

and heals more

circulation.

slowly.
9

9 Inspect skin

Pressure points
over bony

regularly,

prominences

particularly over

are most at risk

bony prominences.

for decreased

Gently massage any

perfusion.

reddened areas and

Circulatory

provide aids such as

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.

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