Student Name: Marvin Berueda

Date Submitted: 11/10/15

Nursing Diagnosis: Impaired Mobility
Related to: Surgical procedure done on both Lower extremities; pain; anxiety
As manifested by: inability to stand up and walk around; limited ROM and reluctance to attempt
movement
Scientific Rationale: Patients surgical procedure on both lower extremities created pain and
impaired the patients ability to ambulate freely.
Outcomes
Interventions
Rationale
Evaluation
1. This promotes a
(measurable)
1. Create a safe
1. Patient was safe
safe
and
secure
environment for
throughout the shift. She did
environment. It
Short Term
patient.
not experience any type of
reduces falls and the fall or other injury.
Patient will be free of 2. Assess ability to
possibility of further
complications of
perform ROM
complications.
immobility as
3. Assess skin
2. Patient expressed pain
2. Assessing her
evidence by no
integrity
with any movement at first.
ROM gives us a
injury, intact skin,
4. Monitor
Once she was sitting up we
baseline of her
normal bowel pattern Nutritional Intake
were able to see her do a few
abilities to move.
and absence of
5. Provide positive
leg extensions with the help
Doing ROM also
thrombophlebitis
reinforcement
allows venous return from her parents. Patient is
and promotes
during activity
able to slightly extend her leg
perfusion.
but not at ninety degrees.
3. Skin integrity could
be a complication
from staying in one
position all day.
Constant monitoring
of the skin prevents
the risk of skin
breakdown
4. Proper nutrition
provides the energy
for ambulation,
provides nutrients for
recovery, and also
helps prevent
pressure ulcers from
forming
5. My patient may be
in pain but her
anxiety heightens
that pain. It is
important to reassure
her that she is doing
well in her
progression. It also

3. Skin was intact upon

assessment. Patient was
able to sit in wheelchair
comfortably which repositions
the body from when she was
lying in bed.
4. Patient was eating well. IV
fluids were stopped and
patient was able to eat
breakfast and lunch.
5. During PT, patient felt like
she was going to fall over.
Constant reassurance that
we were going to keep her
safe allowed her to sit up and
do her ROM. Positive
reinforcement from her
parents also helped.

allows her to feel

accomplished which
is important
according to
Eriksons
psychosocial theory.
Discouragement can
hinder the recovery
process.

Long Term
Patient will have
increased ROM and
have ability to bear
weight and walk
without pain.

Reference: Gulanick, M., & Myers, J.L. (2011). Nursing care plans: Nursing diagnoses,
interventions and outcomes, (7th ed.). St Louis: Mosby.