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

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