ASSESSMENT Subjective: Wala ng nararamdaman ang mga paa ko, pero kapag pinipilit kong igalaw yung bewang

ko may nararamdaman akong parang kuryente. As verbalized by the patient

DIAGNOSIS Impaired physical mobility r/t neuromuscular impairment as evidenced by inability to move lower extremities.

PLANNING After the rotation and nursing intervention the client will be able to : a. Verbalize understanding of situation and individual treatment regimen and safety measures b. Maintain position of function and skin integrity as evidenced by absences of contractures c. Maintain or increase strength and function of affected and/or compensatory body part

INTERVENTION Independent Determine diagnosis that contributes to immobility Asses nutritional status and significant others report of energy level Determine degree of immobility in relation to functional level scale Assist or have significant other reposition client on a regular schedule (turn to side every 2 hours) as ordered by the physician Provides safety measures (side rails up) Support affected body part using pillows

RATIONALE To identify causative / contributing factors

EVALUATION At the end of rotation and nursing intervention the patient was able to: a.Verbalize an understanding of the situation and individual treatment regimen and safety measures b. Maintain position of function and skin integrity as evidenced by absence of contractures c. Maintain or increase strength and function of affected and/or compensatory body part

To assess functional ability and ability to undergo therapy or activities To identify the degree of therapy/interventio n that may be required. To prevent bed sores and promote circulation

Objective: Inability to identify dull and sharp objects, loss of sensations, and inability to move the lower extremities.

To avoid injury To maintain position of function and reduce risk for

pressure sores. Encourage client to participate in self-care and diversional activities Promote adequate intake of fluids and nutritious foods. Dependent Administer medication as ordered by the physician Enhances selfconcept, and promotes independence. To promote wellbeing and maximizes energy production.