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Spina Bifida NCP

The patient reported being unable to feel their feet when walking and being unable to ambulate. On examination, the patient had limited range of motion, decreased muscle function, and reduced sensation in their left upper and lower extremities. The nurse's goals were for the patient to regain functioning within their physical limits and maintain independence. The planned interventions included range of motion exercises, encouraging early ambulation and activity, and assisting with transfers. This was to address impaired mobility due to reduced sensation and to improve strength and mobility.

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Carpz Darpz
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8K views3 pages

Spina Bifida NCP

The patient reported being unable to feel their feet when walking and being unable to ambulate. On examination, the patient had limited range of motion, decreased muscle function, and reduced sensation in their left upper and lower extremities. The nurse's goals were for the patient to regain functioning within their physical limits and maintain independence. The planned interventions included range of motion exercises, encouraging early ambulation and activity, and assisting with transfers. This was to address impaired mobility due to reduced sensation and to improve strength and mobility.

Uploaded by

Carpz Darpz
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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eAssessment Subjective: The patient verbalize naigagalaw ko naman ung paa ko, pero wala ako marandaman kapag

tinatapak ko na, kaya hindi ako makalakad Objective: -limited range of motion -Decreased muscle endurance, stregth, control -Inability to move purposefully within physical environment, including transfers and ambulation -patient has decreased sensation to left upper and lower extremities -patient

Diagnosis

Rationale Inadequate care or improper care of IV insertion can lead to manifestation of infection (eg. Redness, swelling etc) that can agrevate chronic stage of a particular disease.

Planning Goal: Patient will achieve optimal level of functioning w/in physical limits. Objectives After 8 hours of nursing intervention patient: 1. Is free of complications of immobility as eveidenced by intact skin, increase sensation and normal elimmination pattern. 2. Performs physical activity independently or with assistive devices as needed. 3. Be able to maintain and increase existing muscle strength.

Intervention The nurse should be able to: a. Assess patients ability to perform ADLs effectively and safety on a daily basis b. Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe. c. Perform passive or active assistive ROM exerises to all extremities d. Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial changed: dangling, sitting in chair and ambulation

Rationale

Evaluation After 8 hours of nursing interventions, the client was be able to:

impaired physical mobility r/t decreased tactile sensorium on left side.

- Restricted movement affects the ability to perform most ADLs Safety with ambulation is an important concern. - to facilitate improvement and independence therefore, increasing patients self esteem - exercise promotes increased venous return, prevents stiffness and maintains muscle stregth and endurance.

all the interventions were met which was made evident by the absence of sign and symptom related to infection.

- The longer the patient remains immobile the greater the level of debilitation that will occur, dependency on ADLs will be limited.

e. Administer meds as ordered

To prolon

f.

Assist in performing deep brain stimulation

g. Refer patient to a physical therapist

h. Collaborate with a speech therapist for problems with phonation.

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