ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

EXPLANATION

SUBJECTIVE Self care spinal cord After 2 hrs. of  Assess the  The patient After 2 hrs. of
“nahihirapan deficit injury nursing patient’s may only nursing
akong kumilos related to interventions, strength to need help interventions,
dahil sa sitwasyon spinal cord the client will accomplish with some
the client was
ko” as verbalized injury as be able to ADLs self-care
by the patient evidenced damage to increase efficiently and measures. able to increase
by the nerves strength of cautiously on Self-care strength of
paraplegia. unaffected/com a daily basis items related unaffected/com
OBJECTIVE pensatory body using a proper to eating, pensatory body
 Paraplegia parts. assessment bathing, parts.
 Impaired Impaired tool, such as grooming,
physical Physical the Functional dressing,
immobilit Mobility Independence toileting, blad
y Measures der and bowel
management.
 Perform and  Enhances
assist with circulation,
Passive ROM restores and
exercises on maintains
all unaffected muscle tone
extremities and joint
and joints, mobility, and
using slow, prevents
smooth disuse
movements. contractures
and muscle
 Implement atrophy.
measures to  An
promote appropriate
independence, level of
but intervene assistive care
 when the can prevent
patient cannot injury from
function. activities
without
causing
frustration.
Nurses can be
key in helping
patients
accept both
temporary and
 Allow the permanent
patient to feed dependence.
herself as
soon as  It is possible
possible that the
(using the dominant
unaffected hand will also
hand). Assist be the
with setup as affected hand
needed. if there is
upper
 Advice the extremity
significant involvement.
others to
Consider the  A large size
use of guarantees
clothing one easier
size larger to dressing and
the patient. comfort.