ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
SUBJECTIVE: Impaired Spinal cord After 8 hours of Continually asses Evaluates status of After 8 hours of
physical injury may result nursing motor function (as individual situation nursing
Hindi ako mobility related from trauma, interventions, the spinal shock or (motor-sensory interventions,
makagalaw as to vascular patient will edema resolves) by impairment may be the patient was
verbalized by the neuromascular disruption, demonstrate requesting patient to mixed and/ or not able to
patient. impairment. infection, tumor, techniques or perform certain clear) for a specific demonstrate
and other insults. behaviors that actions. level of injury, techniques or
OBJECTIVE: The injury may enable affecting type and behaviors that
be partial or resumption of choice of enable
Paralysis on complete and activity. intervention. resumption of
the lower vary from a mild Provide means to activity.
extremities cord concussion summon help. Enables patient to
Muscle with transient have sense of
atrophy numbness to control, and reduces
Irritability complete cord fear of being left
V/S taken as transaction Assist in range of alone.
follows: causing motion exercises on
immediate and all extremities and Enhances circulation,
T: 37.5 permanent joints, using slow, restores or maintains
P: 99 tetraplegia. The smooth movements. muscle tone and joint
R: most common mobility, and prevent
Mechanical sites of injury are disuse contractures
Ventilator the cervical Plan activities to and muscle atrophy.
supported areas C5, C6,
provide uninterrupted
BP: 120/70 and C7, and the Prevents fatigue,
rest periods.
junction of the
Encourage allowing opportunity
thoracic and
involvement within for maximal efforts or
lumbar
individual tolerance or participations by
vertebrae, T12
ability. patient.
and L1. Clinical
Reposition
manifestations
vary with the periodically even
when sitting in chair. Reduces pressure
location and
severity of cord Teach patient how to areas, promotes
damage. In use weight-shifting peripheral circulation.
general, techniques.
complete
transaction Inspect the skin daily.
causes loss of all Observe for pressure Altered circulation,
function below areas, and provide loss of sensation, and
the level of meticulous skin care. paralysis potentiate
lesion, and pressure sore
incomplete cord formation.
damage results Collaborative:
in a variety of Consult with physical
regional deficits. or occupational Helpful in planning
Complications therapist. and implementing
include shock, individualized
respiratory or exercise program and
cardiac arrest, identifying or
thromboembolis developing assistive
m, infections, devices to maintain
and autonomic function, enhance
dysreflexia. mobility and
independence.
Administer muscle
relaxants or May be useful in
antispasticity as limiting or reducing
prescribed. pain associated with
spasticity