ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION

•Objective: •Impaired •Muscle spasm can •Goals: •Perform • Once one • After 1
- Spastic physical be defined as - After 1 week of development milestone is week of
quadriple mobility persistent, nursing assessment achieved, nursing
gia related to involuntary muscle interventions, and record age interventions interventions,
- Epilepsy decrease contraction (not the patient will of achievement are revised to the patient
including spasticity, a of milestones
muscle be able to attain assist in the have attained
phenomenon of (e.g., reaching
control as maximum new skill maximum
central nervous for objects,
manifested physical abilities necessary physical
origin). The main sitting)
by inability possible. abilities
reason why pain
to control - After 2 weeks of • Many possible.
arises in muscle •Plan activities
lower nursing activities of •After 2
spasm is muscle to use gross
interventions,
extremities ischemia, which leads and fine motor daily living and weeks of
the patient will
and muscle to a drop in pH and skills (e.g., play activities nursing
be able to
spasm. the release of pain- holding pen or promote interventions,
engage in
producing substances eating utensils, physical the patient
adequate
such as bradykinin, toys positioned development. have to
diversional
ATP, and H+. to encourage
activity to engaged in
maximize growth reaching and adequate
rolling over)
and diversional
development. •Allow time for •The patient activity that
•Objective/s: the child to
may perform maximized
complete
- After 1 week of tasks slower her growth
activities
nursing than most and
interventions, children development.
the patient will
•Perform
be able to • Promotes
range-of-
improve her motion mobility and
posture and exercises every increase
can do simple 4 hours for the circulation, and
motor skills child unable to decreases the
independently. move body risk of
parts. Position contractions.
the child to
promote
tendon
stretching (e.g.,
foot plantar
flexion instead
of dorsiflexion,
legs extended
instead of
flexed at knees
and hips)
•Assess for •Identify the
impediments specific cause
to mobility guides design of
optimal
treatment plan.
•Assess •Restricted
patient’s movement
ability to affects the
perform ADLs ability to
effectively perform most
and safely on ADLs. Safety
a daily basis. with
ambulation is
an important
concern.
•Evaluate •Proper use of
need for wheelchairs,
assistive
devices. canes, transfer
bars, and other
assistance can
promote
activity and
reduce danger
•Encourage of fails.
and facilitate •The longer the
early patient remains
ambulation immobile the
and ADLs greater the
when possible level of
debilitation that
•Provide will occur.
positive •Patients may
reinforcemen be reluctant to
t during move or initiate
activity with new activity
the use of from a fear of
assistive falling.
devices.
•Allow
patient to •Hospital
perform tasks workers and
at her own family
rate. Do not caregivers are
rush the often in a hurry
patient. and do more
for patients
than needed,
thereby slowing
patient’s
 recovery and
reducing his or
her self-
esteem.

•Keep side
rails up and •To promote
bed in low safe
position. environment.
•Maintain
limbs in •To prevent
functional foot drop
alignment and/or
(e.g., with excessive
pillows plantar flexion
sandbags, or tightness.
wedges, or
prefabricated
splints).
•Support feet
in dorsiflexed •To keep heavy
position (use bed linens off
bed cradle) feet.
•Perform
passive or • To promote
active increased
assistive ROM venous return,
exercises to prevent
all stiffness, and
extremities. maintain
muscle strength
and endurance.