Republic of the Philippines

Bicol University Polangui Campus

NURSING AND HEALTH SCIENCES DEPARTMENT
S.Y 2018-2019

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE:
+ impaired “Impaired Physical
coordination Mobility r/t perceptual or
cognitive impairment as
+ decreased muscle
evidenced by impaired
strength
coordination and
+ poor motor control decreased muscle
strength and control”
INDEPENDENT:
After 8 hours of nursing 1. Change positions at  Reduces risk of After 8 hours of nursing
intervention, the patient least every 2 hours tissue ischemia intervention, the patient
will maintain or increase (supine, side lying) and injury. was able to maintain or
strength and function of and possibly more Affected side has increase strength and
affected or often if placed on poorer circulation function of affected or
compensatory body affected side. and reduced compensatory body
part. sensation and is part.
more
predisposed to
skin breakdown
2. Place pillow under and pressure
axilla to abduct arm. ulcers.
 Prevents
3. Elevate arm and adduction of
hand. shoulder and
flexion of elbow.
 Promotes venous
4. Place knee and hip return and helps
in extended position. prevent edema
5. Observe affected formation.
side for color,  Maintains
edema, or other functional
signs of position.
compromised  Edematous tissue
circulation. is more easily
 traumatized and
heals more
slowly.
6. Begin active or  Minimizes
passive ROM to all muscle atrophy,
extremities (including promotes
splinted) on circulation, and
admission. helps prevent
Encourage contractures.
exercises, such as
quadriceps or gluteal
exercise, squeezing
rubber ball, and
extension of fingers
and legs and feet.
7. Assist client to  Aids in retraining
develop sitting neuronal
balance (such as pathways,
raise head of enhancing
bed; assist to sit on proprioception
edge of bed, having and motor
client use the response.
strong arm to
support body weight
and strong leg to
move
affected leg;
increase sitting time)
and standing
balance—
put flat walking
shoes on client,
support client’s lower
back
 with hands while
positioning own
knees outside
client’s
knees, and assist in
using parallel bars
and walker.
8. Set goals with  Promotes sense
client/significant of expectation of
other (SO) for progress and
increasing improvement,
participation and provides
in activities, exercise, some sense of
and position control and
changes. independence.

COLLABORATIVE
1) Consult with physical  Individualized
therapist regarding program can be
active, resistive developed to
exercises and client meet particular
ambulation. needs and deal
with deficits in
balance,
coordination, and
strength.
2) Administer muscle  May be required
relaxants and to relieve
antispasmodics as spasticity in
indicated, affected
such as baclofen extremities.
(Lioresal) and
dantrolene
(Dantrium).