Assessment

Diagnosis

Planning
Short term:

Subjective:
Hindi ko
na
maigalaw
ang mga
binti ko.
Patients
verbalizati
on
Objective:

Limited
range of
motion
Right and
left leg
paralysis
Loss of
sensation
in legs
Ascending
paralysis

Impaired
Physical
Mobility
related
to
decreased
strength and
endurance
secondary to
lower
leg
paralysis
Definition:
The state in
which
an
individual
experiences
limitation of
physical
movement
but
is
not
immobile.
It
describes an
individual
with
limited
use of arm(s)
or leg(s) of
limited
muscle
strength

Within an
hour of
nursing
intervention,
the patient
will verbalize
understandin
g of situation
and individual
treatment
regimen and
safety
measures

Long term:

After 8 hours
of nursing
intervention,
the client will
maintain or
increase
strength and
function of
affected
and/or
compensatory
body part

Intervention
Independent:
Established
rapport

Vitals were
assessed and
noted
Motor function
were assessed

Provided
bedside
commode
Encouraged
participation in
self-care and
recreational
activities
Provided
safety
measure as
indicated by
individual
situation,
including fall
prevention

Rationale

To gain
clients
cooperation
and trust
To provide
baseline
data

To help
determine
appropriate
intervention
for specific
motor
impairment

To limit
fatigue and
conserve
energy

To enhance
self-concept
and sense
of
independen
ce

To prevent
further
injury and

Evaluation
Short term
After an
hour of
interventio
n, client
verbalized
understan
ding of
situation
and
individual
treatment
regimen
and safety
measures.
Goal was
met
Long term:
After 8
hours of
interventio
n, client
was not
able to
maintain
or increase
strength
and
function of
affected
body part.

Assisted with
range of
motion
exercises on
extremities

complicatio
ns

To maintain,
restore or
maintain
muscle tone
and prevent
muscle
atrophy

Goal was
not met