Roxxanne M. Buenviaje Group 4 - SLCN Assessment Subjective: Medyo hirap lang siya kumilos dahil sa nakakabit sa ulo niya.

As verbalized by the relative Objective: Seen attached to a head halter traction Limited range of motion Difficulty turning Weakness Functional Level: 2 Diagnosis Impaired physical mobility r/t restrictions of movement secondary to dislocation of C1 and C2 Planning Short-term goals: After 30mins of effective nursing intervention, client will: Understand the situation and importance of safety measures Still comply to ADLs and desired activities with assistance Long-term goals: After 2hrs s of effective nursing intervention, client will: Maintain/ increase strength and function by performing passive ROM Be at ease and comfortable Intervention Provided proper information about the condition and importance of traction Instructed the relative to assist the client to maintain ADLs such as tooth brushing, bathing, and playing toys Performed Passive ROM such as bending knees and elbows and stretching Advised to provide extra pillows of blanket if desired by the patient Assisted or have the client reposition self on regular schedule Rationale To understand condition and avoid misconception Evaluation Short-term goals: After 30mins of effective nursing intervention, clients relative was able to understand condition and importance and its safety and the client was able to perform ADLs therefore, goal was met.

Limits fatigue and maximize participation

Prevent muscle atrophy and weakness Long-term goals: After 2hrs of effective nursing intervention, client was able to perform Passive ROM and was comfortable thereafter, therefore, goal was met.

To be comfortable

For position changes and prevent bed sores

Roxxanne M. Buenviaje Group 4 - SLCN Assessment Subjective: Nung isang linggo pa siya nakaconfine dito . Nakahiga lang siya simula noon. As verbalized by the relative Objective: Awake; coherent; at the bed Diagnosis Increased risk of cardiovascular, bowel and skin complications r/t to a long period of immobility Planning Short-term goals: After 30mins of effective nursing intervention, client will: Have the awareness of the risk of complications Practice voiding pattern Perform Passive ROM and elevate feet Perform respiratory exercises Long-term goals: After 2hrs s of effective nursing intervention, client will follow instructions given and will be free from the risk of complication r/t a long period of immobility Intervention Provided proper information regarding the risk of having complications due to a long period of immobility Assisted the client in making voiding schedule and advised to strictly follow it Monitored intake and output Assisted in performing Passive ROM Elevated the feet Turn patient q2hrs Demonstrated respiratory exercises such as deep breathing and coughing techniques Rationale For awareness of the possibility of complications Evaluation Short-term goals: After 30mins of effective nursing intervention, clients relative was able to understand the possibility of complications due to prolong immobility and client was able to follow voiding schedules and performed Passive ROM therefore, goal was met.

To prevent UTI

To monitor any deviations To promote proper circulation Prevent edema Prevent from bed sores Prevent lung complications Long-term goals: After 2hrs s of effective nursing intervention, client was able to follow instructions give and now is free from possible complications of respiratory, bowel, cardiovascular and skin due to prolong immobility.