Impaired Comfort Risk for Disuse Syndrome
Pain Risk for Impaired Skin Integrity
Saan? ____________ Risk for Constipation
Dahilan? ____________ Risk for Altered Respiratory Function
Kailan? ____________ Risk for Ineffective Peripheral Tissue Perfusion Risk for
Oras? ____________ Infection
Dalas? ____________ Risk for Activity Intolerance
Haba? ____________ Risk for Impaired Physical Mobility
Lakas? ____________ (1-10) Risk for Injury
Paano mag-react? ____________ Powerlessness
Kaakibat na sintomas? ____________ (pagkahilo, pagsusuka, Disturbed Body Image
pagkamanhid)
Epekto? ____________________________________
Acute vs. Chronic: <6 months or >6 months
Pruritus
Saan? ____________
Dahilan? ____________
Kailan? ____________
Oras? ____________
Dalas? ____________
Haba? ____________
Impaired Physical Mobility
Impaired Bed Mobility
Impaired Walking
Impaired Wheelchair Mobility
Impaired Transfer Ability
6 P’s
Neurovascular Early or Assessment Client Teaching/
Component Late Parameters Symptoms to
Report
Pain Early Assess area Increasing pain
involved using 0 to not relieved with
10 rating scale elevation or pain
medication
Paresthesia Early Assess for Numbness or
numbness/tingling, tingling, pins or
pins, or needles needles
sensation: should be sensation
absent
Pallor Early Assess capillary Increased
refill: capillary refill
Brisk is <3 seconds time >3 seconds,
blue fingers or
toes
Polar Late Assess skin temp by Cool/cold fingers
touch: or toes
- Warm or Cool
Risk for Injury Paralysis Late Assess mobility: Unable to move
- Moves finger or fingers or toes
toes
- Able to plantar
dorsiflex the ankle
area not involved or
restricted by cast
Pulses Late Assess pulse(s) Weak palpable
distal to injury pulses, unable to
palpate pulses
HEALTH HISTORY
• Occupation (eg, does the patient’s work require physical activity or
heavy lifting?),
• Exercise patterns
• Dietary intake (eg, calcium and vitamin D).
• Concurrent health conditions (eg, diabetes, heart disease, chronic
obstructive pulmonary disease, infection, preexisting disability)
• Related problems, such as familial or genetic abnormalities
(Osteoporosis, Scoliosis)
PAIN
• Is the body in proper alignment?
• Is there pressure from traction, bed linens, a cast, or other
appliances?
• Is there tension on the skin at a pin site?
Bone pain is characteristically described as a dull, deep ache that
is “boring” in nature
Muscular pain is described as soreness or aching and is referred
to as “muscle cramps.”
Fracture pain is sharp and piercing and is relieved by
immobilization.
Sharp pain may also result from bone infection with muscle
spasm or pressure on a sensory nerve.
PARESTHESIA
• If the abnormal sensation or feeling of numbness involves an
extremity, how does this feeling compare to sensation in the unaffected
extremity?
• When did the condition begin? Is it getting worse?
OTHERS
• Is a pulse distal to the affected area palpable? If the affected area is
an extremity, how does the pulse compare to the pulse of the
unaffected extremity?
• Is edema present?
• Is any constrictive device or clothing causing nerve or vascular
compression?
• Does elevating the affected part or modifying its position affect the
symptoms?
JOINT FUNCTION
• Joint Effusion- Balloon Sign and Ballottement Sign
• Crepitus-__________ Nodules around tendons/ joints-_________
• Asymmetry:____________
• Swan Neck? (For rheumatoid arthritis)
MUSCLE SIZE AND STRENGTH
• Clonus (rhythmic contractions of a muscle) in the ankle or wrist by
sudden, forceful, sustained dorsiflexion of the foot or extension of the
wrist.
• Fasciculation (involuntary twitching of muscle fiber groups) may be
observed.
