1. Impaired Physical Mobility related to neuromuscular damage.
Goal / Outcomes:
Maintain body function with no complications (contractures, pressure sores).
Nursing Intervention :
Independent
1. Assess the strength of the motor / functional abilities using a scale of 0-5.
R /: Specifies the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.
2. Provide patient positioning lead to a sense of comfort.
R /: Reduce fatigue, enhance relaxation, reduce the risk of ischemia / damage to the skin.
3. Chock extremities and joints with pillows.
R /: Maintaining the limb in a position fisilogis, prevent contractures and loss of joint function.
4. Perform passive range of motion exercises.
R /: Stimulates circulation, improve muscle tone and increase joint mobilization.
Collaboration
5. Confirm with / refer to the physical therapy / occupational therapy.
2. Anxiety related to situational crisis.
Goal / Outcomes:
Appear relaxed and report anxiety is reduced to the level can be overcome.
Nursing Interventions:
Independent
1. Place the patient near the nurses' station, check the patient regularly.
R /: To provide assurance that immediate assistance can be done if the patient suddenly becomes not have the ability.
2. Provide primary care / nurse relationships are consistent.
R /: Improve mutual trust of patients and help to reduce anxiety.
3. Provide alternative forms of communication if necessary.
R /: Reduce feelings of helplessness and feelings of isolation.
4. Discuss the change in self-image, fear of losing the ability to settle, loss of function, death, problems regarding the need penyebuhan / repair.
Collaboration
5. Provide a brief description of the treatment, the patient's treatment plan, including the closest.
R. /: A good understanding can increase the need for patient cooperation activities and the involvement of patients and also the closest in care planning will be able to maintain some sense of control over themselves for life which will further enhance the self-esteem.
3. Knowledge Deficit related to less remembering, cognitive limitations.
Goal / Outcomes:
Patients know and understand about the disease.
Nursing Interventions:
Independent
1. Determine the patient's knowledge and ability to participate in the rehabilitation process.
R /: Influencing choice of interventions that will be done.
2. Review the patient's knowledge about the disease and its prognosis.
R /: The knowledge base is an important thing to make informed choices and participate in rehabilitation efforts.
3. Suggest to reveal what is in the natural, social, and increase independence.
R /: Increasing returns to normal and the development of his feelings on the situation.
4. Identify safety measures to find defeswit sensory-motor individually.
R /: Reduce the risk of injury / lower the actual risk of complications can still be prevented.
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