BISHOP STATE COMMUNITY COLLEGE NURSING PROGRAM PLAN OF CARE

NAME: Chrystal McNeal DATE: 04/04/2012 ASSESSMENT ASSESSMENT SUBJECTIVE OBJECTIVE

1 limited range of motion (ROM) 2 inability to perform activities as instructed 3 inability to move purposefully within physical environment including bed mobility, transfers, and ambulation.

NURSING DIAGNOSIS

PLANNING PATIENT GOALS

Patient is free of complications of immobility as evidence by intact skin, absence of thrombophlebitis, normal bowel pattern, and clear breath sounds.

PLANNING NURSING INTERVENTIONS

1 Assess skin integrity for signs of redness and tissue ischemia. 2 administer medications as appropriate. 3 provide a safe environment bed rails up, bed in lowest position, necessary items close by. 4 Clean, dry, and moisturize skin as needed to prevent skin breakdown from prolonged immobility. 5 set up a bowel program such as stool softeners or laxatives as needed and record bowel activity.

RATIONALE

Impaired physical mobility related to Multiple Sclerosis

1 regular examination of the skin will allow for prevention or early recognition and treatment of pressure ulcers. 2 antispasmodic medications may reduce muscle spasms or spasticity that interferes with mobility; analgesic may reduce pain that impedes movement. 3 these measures promote a safe environment and may reduce risk for falls. 4 these measures reduce skin breakdown. 5 Prolonged bed rest, lack of exercise, and physical inactivity contribute to constipation. A variety of interventions will promote normal elimination.