Assessment Diagnosis Planning Intervention Rationale evaluation

Impaired After 8 hours of Independent: Evaluates status of

physical nursing • Continually asses individual situation
mobility related interventions, the motor function (as (motor-sensory
to patient will spinal shock or edema impairment may be
neuromascular demonstrate resolves) by mixed and/ or not
impairment. techniques or requesting patient to clear) for a specific
behaviors that perform certain level of injury,
enable actions. affecting type and
resumption of • Provide means to choice of intervention.
activity. summon help. • Enables patient to
• Assist in range of have sense of control,
motion exercises on all and reduces fear of
extremities and joints, being left alone.
using slow, smooth • Enhances circulation,
movements. restores or maintains
• Plan activities to muscle tone and joint
provide uninterrupted mobility, and prevent
rest periods. disuse contractures
Encourage and muscle atrophy.
involvement within • Prevents fatigue,
individual tolerance or allowing opportunity
ability. for maximal efforts or
• Reposition participations by
periodically patient.
even when sitting in • Reduces pressure
chair. Teach patient areas, promotes
how to use peripheral circulation.
weightshifting • Altered circulation,
techniques. loss of sensation, and
• Inspect the skin daily. paralysis potentiate
Observe for pressure pressure sore
areas, and provide formation.
meticulous skin care. • Helpful in planning
Collaborative: and implementing
• Consult with physical individualized
or occupational exercise program and
therapist. identifying or
• Administer muscle developing assistive
relaxants or devices to maintain
antispasticity as function, enhance
prescribed. mobility and
independence.
• May be useful in
limiting or reducing
pain associated with
spasticity