49310440 ncp impaired physical mobility

7/28/2019 49310440 NCP Impaired Physical Mobility

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NCM104bBSN220/Group 8

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Cues NursingDiagnosisAnalysis Planning Intervention Rationale EvaluationSubjective:Ang hirap ng may ganito (traction). Bawal kumilos, hindi man lang ako makapunta sa banyo para maligo.Hinihintay ko pa na may bisita ako paralang makapaglinisng sarili ko verbalized by the client.

Objective: Client is on modified bucks extension traction.Client is on semi- fowlers position. Client hadfracture on theproximal 3rd ofhis left femur due to gunshot.Client had three gunshots on his abdomen with mainly his duodenum and jejunum aswellas in his right leg.Provisional Diagnosis: Hypovolemic shock 2 to multiple GSW

Measurement:Red Blood Cells3.77 x 10^12/LImpairedPhysical Mobility related to musculoskeletal impairment possibly evidenced by inability to move purposefully within the physical environment, imposedrestriction.Impaired PhysicalMobility Limitation in independent, purposeful physical movement of the body orof one or more extremities. (Nurses Pocket Guide-Diagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, MaryFrances Moorhouse, Alice C. Murr

p.457)

Alteration in mobility may be a temporaryor more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g.,as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of diseaseand disability continues to grow. And with shorter hospital stays,patients are being transferred to rehabilitationGoals:After 8 hours of nursing intervention, the client will be able to verbalize understanding of situation and individual treatment regimen and safety measures independently.

Objectives:After 1 hour of nursing intervention, the client will be able to:1.To identify at least five out of eightcausative/contributingfactors


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Determine diagnosis that contributes to immobility

Note factors affecting current situation and potential time involved.

Assess clients developmental level, motor skills, ease and capability of movement

, posture and gait.

Note older clients general health status

These conditions can cause physiological and psychological problems that can seriously impact physical, social, and economic well-being.

Identifies potential impairments and determines type of interventions needed toprovide for clients safety

To determine presence of characteristics of clients unique impairment and to guid

echoiceofinterventions

Identified mobility as the most important functional ability that determines thedegree of independence and healthcare needs among older persons.2While aging per se does not cause impairedmobility, severalThe goal was met.


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Met. The client was able to identify five out of eight causative/contributing factors.Normal Findings: (Males) 5.5-6.5 x10^12/LHemoglobin11.80 g/dL Normal Findings: (Males) 14-16 g/dLHematocrit0.33 L/LNormal Findings:(Males) 0.42-0.52L/LLymphocytes

0.21Normal Findings:0.25-0.35Eosinophils0.01Normal Findings0.03-0.05

facilities or sent home for physical therapyin the home environment.

Mobility is also related to body changes from aging. Loss of muscle mass, reduct

ion in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independentliving. Restricted movement affects the performance of most activities of dailyliving (ADLs).Elderly patients are also at increased riskfor the complicationsof immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment.

(Nursing Care Plans: Nursing Diagnosis and Intervention by Gulanick, Myers,


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Determinedegreeof perceptual/cognitiveimpairment andabilitytofollowdirectionspredisposing factors inadditiontoage-relatedchanges canleadtoimmobility

Todetermineneededinterventions forpainmanagement

Helps to determine clients expectations/beliefsrelated to activity andpotential long-term effectofcurrentimmobility.Also identifiesbarriersthatmaybe addressed

Deficiencies in nutrients and water,electrolytesandminerals cannegativelyaffectenergyand activitytolerance.

Client may be restricting activity because of weakness/debilitation, actual injury during a fall, or from psychological distressthatcanpersistafterafall.

Identifies strengths and deficitsimpaired physical mobilityand may provide information regarding potential for recovery

Impairments related to age, chronic or acute disease condition, trauma,


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Met. The client was able to report three out of five of his functional ability.

Klop, Galanes, Gradishar and Puzas)

Observemovementwhenclient isunawareofobservation

Noteemotional/behavioral responsestoproblemsof immobility

Determinepresence of complicationsrelatedto immobilitysurgery, or medications require alternative interventions or changes in plan ofcare.

To note any incongruence withreportsofabilities.

Can negatively affect self- concept and self-esteem, autonomy, and independence.Feelings of frustration and powerlessness mayimpede attainment of goals. Social,occupational, and

relationship roles can change, leading to isolation, depression, and economic consequences

Studies have shown that as much as 5.5% of muscle strength can be lost each dayof rest and immobility.5 Other complications include changes in circulation andimpairments of organ function affecting the whole person

3.To explain at least five of the optimal level of function and measures on howto prevent complications.Assistwithtreatmentof underlyingcondition(s)


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Discuss discrepancies in movement with client aware and unaware of observation and methodsfordealingwith identifiedproblems.

Assist/haveclientrepositionselfTo maximize potential for mobility and optimal function.

May be necessary when client is using avoidanceor controlling behavior, or is not aware of own abilities due to anxiety/fear.

To enhance circulation toMet. The client was able to explain at least five of the optimal level of function and measures on how to prevent complications.onaregularscheduleasdictated byindividualsituation

Review/encourageuseofproper bodymechanics

Demonstrate/assistwithuseof siderails,overhead trapeze,roller pads,hydrauliclifts/chairs

Supportaffected body parts/jointsusingpillows/rolls, footsupports/shoes,gelpads,etc.,

Provide/recommend egg-crate, alternatingair-pressure, orwater mattress.

Usepaddingandpositioning devices

Encourage clients participation in self-care activities, physical/occupational therapies as well as diversional/recreational activities.

Provide client with ample time to perform mobility-related tasks. Schedule activities with adequaterestperiodsduringthe day

Avoidroutinelyassistingor doingforclientthoseactivities thatclientcandoforself.

Identify/encourageenergy- conservingtechniquesfortissues, reduce risk of tissue ischemia.

Topreventinjurytoclientand caregiver

Forpositionchanges/transfers. Instructinsafeuseofwalker/cane forambulation.

Tomaintainpositionoffunction andreduce riskofpressureulcers.

Reduces tissue pressureandaidsinmaximizing cellularperfusiontopreventdermal injury.

To prevent stress on tissues and reduce potential for disusecomplications.

Reduces sensory deprivation, enhances self- concept andsenseofindependence,and improvesbodystrengthand function.

Toreducefatigue.


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Caregivers cancontributetoimpairedmobility bybeingoverprotective orhelping toomuch.

Limits fatigue, maximizingADLs.

Notechangeinstrengthtodo moreorlessself-care

Administermedicationsbefore activityasneededforpainrelief

Perform/encourageregular skin examinationandcare

Encourageadequate intakeof fluids/nutritiousfoods

Encourageclients/SOs involvementindecisionmaking asmuchaspossibleparticipation.

To promote psychological and physical benefits of self-care and to adjust levelof assistance asindicated.

To permit maximal effort/involvementinactivity.

To reduce pressure on sensitive areas and to prevent development of problems with skin integrity.

Promotes well-being and maximizes energy production.

Enhances commitment to plan, optimizing outcomes.

4.To discuss four out of five of wellness program.

Discusssafewaysthatclientcan exercise

Assistclient/SOtolearnsafety measuresasindividually indicated.

Involve client and SO(s) in care, assisting them to learn ways of managing problems of immobility,especiallywhen impairmentisexpected tobe long-term.Multipleoptionsprovideclient choicesandvariety


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May need instruction and togivereturndemonstration

May need referral for support and community services to provide care, supervision, companionship, respite services,nutritional and ADLassistance, adaptive devices or changes to living environment, financialassistance, etc

Met. The client was able to discuss four out of five of wellness program.

Demonstrate use of standing aids and mobility devices and have client/careprovider demostrate knowledge about/safeuse of device. Identify appropriate resources forobtaining andmaintaining appliances/equipment.Safe use of mobility aids promotes clients independence and enhances quality of lifeandsafetyforclientand caregiver(Nurses Pocket Guide- Diagnoses, Prioritized Interventions, and Rationales by M

arilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr p.458-461)

49310440 ncp impaired physical mobility

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