Disuse Syndrome

Disuse
Syndrome

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Unconciousness
(_) Neuromuscular Impairment
(_) Musculoskeletal condition

(_) Immobility
(_) Traction/casts/splints
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(Must be
present
)

(_)
Presence of risk factors. (See above “Related
To”).

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target

Date:

Nursing Interventions
[Check
those that apply]
Date
Achieved:
  The
patient will:

(_)
Maintain or regain free range of motion of extremities
within limits of disease.

(_) Maintian or regain
function of:___________
___________
within limits of disease.

(_) Other:

  (_)
Assess range of motion of affected extremities and the
ability of patient to perform ADL’s.

(_) Consult with PT/OT
regarding necessary exercises/assistive devices.

(_) Range of motion
to____________ extremities ____________ times a day.

(_) Splints to
_________________. Apply during __________. Remove for
_______________.

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature