Impaired Comfort Risk for Disuse Syndrome

Pain Risk for Impaired Skin Integrity


Saan? ____________ Risk for Constipation

Dahilan? ____________ Risk for Altered Respiratory Function

Kailan? ____________ Risk for Ineffective Peripheral Tissue Perfusion Risk for
Oras? ____________ Infection 

Dalas? ____________ Risk for Activity Intolerance

Haba? ____________ Risk for Impaired Physical Mobility
Lakas? ____________ (1-10) Risk for Injury

Paano mag-react? ____________ Powerlessness

Kaakibat na sintomas? ____________ (pagkahilo, pagsusuka, Disturbed Body Image 

pagkamanhid)
Epekto? ____________________________________
Acute vs. Chronic: <6 months or >6 months

Pruritus
Saan? ____________
Dahilan? ____________
Kailan? ____________
Oras? ____________
Dalas? ____________
Haba? ____________

Impaired Physical Mobility

Impaired Bed Mobility
Impaired Walking

Impaired Wheelchair Mobility
Impaired Transfer Ability
 6 P’s
Neurovascular Early or Assessment Client Teaching/
Component Late Parameters Symptoms to
Report
Pain Early Assess area Increasing pain
involved using 0 to not relieved with
10 rating scale elevation or pain
medication
Paresthesia Early Assess for Numbness or
numbness/tingling, tingling, pins or
pins, or needles needles
sensation: should be sensation
absent
Pallor Early Assess capillary Increased
refill: capillary refill
Brisk is <3 seconds time >3 seconds,
blue fingers or
toes
Polar Late Assess skin temp by Cool/cold fingers
touch: or toes
- Warm or Cool
Risk for Injury Paralysis Late Assess mobility: Unable to move
- Moves finger or fingers or toes
toes
- Able to plantar
dorsiflex the ankle
area not involved or
restricted by cast
Pulses Late Assess pulse(s) Weak palpable
distal to injury pulses, unable to
palpate pulses
HEALTH HISTORY
• Occupation (eg, does the patient’s work require physical activity or
heavy lifting?),
• Exercise patterns
• Dietary intake (eg, calcium and vitamin D).
• Concurrent health conditions (eg, diabetes, heart disease, chronic
obstructive pulmonary disease, infection, preexisting disability)
• Related problems, such as familial or genetic abnormalities
(Osteoporosis, Scoliosis)

PAIN
• Is the body in proper alignment?
• Is there pressure from traction, bed linens, a cast, or other
appliances?
• Is there tension on the skin at a pin site?

 Bone pain is characteristically described as a dull, deep ache that

is “boring” in nature
 Muscular pain is described as soreness or aching and is referred
to as “muscle cramps.”
 Fracture pain is sharp and piercing and is relieved by
immobilization.

 Sharp pain may also result from bone infection with muscle
 spasm or pressure on a sensory nerve.

PARESTHESIA
• If the abnormal sensation or feeling of numbness involves an
extremity, how does this feeling compare to sensation in the unaffected
extremity?
• When did the condition begin? Is it getting worse?

OTHERS
• Is a pulse distal to the affected area palpable? If the affected area is
an extremity, how does the pulse compare to the pulse of the
unaffected extremity?
• Is edema present?
• Is any constrictive device or clothing causing nerve or vascular
compression?
• Does elevating the affected part or modifying its position affect the
symptoms?

JOINT FUNCTION
• Joint Effusion- Balloon Sign and Ballottement Sign
• Crepitus-__________ Nodules around tendons/ joints-_________
• Asymmetry:____________
• Swan Neck? (For rheumatoid arthritis)

MUSCLE SIZE AND STRENGTH

• Clonus (rhythmic contractions of a muscle) in the ankle or wrist by
sudden, forceful, sustained dorsiflexion of the foot or extension of the
wrist.
• Fasciculation (involuntary twitching of muscle fiber groups) may be
observed.