NURSING CARE PLAN

PROBLEM: Immobility
NURSING DIAGNOSIS: Impaired physical mobility r/t spinal injury secondary to VA.
GORDONS: Activity-exercise pattern
CAUSE ANALYSIS: The most obvious signs of prolonged immobility are often manifested in the musculoskeletal system. Thus, when the spinal injury happens, a person’s
physical mobility will be impaired. Fundamentals of Nursing by Kozier p 567)
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE: STO: INDEPENDENT:
 Spaced nursing activities.  Clustering activities
After 8 hours of effective increases myocardial
NO VERBAL CUES nursing care, patient will be demand and may cause
reposition frequently to promote extreme fatigue. After 8 hours of effective
circulation and relieves pressure  Evaluated degree of  Level of activity depends nursing care, patient was
on tissues. fracture or injury. on progression of injury. repositioned frequently. And was
 Assisted with active/  Improves joint function relieved from pressures on tissue.
OBJECTIVES: LTO: passive ROM as and general stamina.
 Reduced skin turgor indicated.
 Loss of consciousness After 2 days of nursing care  Repositioned frequently  Relieves pressure on
 GCS-3 implementation, patient will have using adequate tissues and promoted After 2 days of duty with
 Negative muscle strength a maintain position of function as personnel. circulation. Proper continued implementation of
evidenced by reduced foot drop. transfer techniques nursing care, patient has a
 Presence of cast on upper
left arm prevent shearing abrasion maintained position of function.
 Foot drop- 45 degrees of skin.
 Positioned with pillows.  Promotes joint stability
Provide joint support and maintains proper
with splints. joint position and body
alignment.
 Provided footboard.  To reduced the foot drop.

REFERENCE: NCP 6th edition by Doenges