NURSING

NURSING GOALS AND

CUES ANALYSIS INTERVENTI RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
ON
Alteration in
Subjective: Impaired mobility may Goals:
-“Okay Physi be a After nursing
naman ang cal temporary or intervention,
pakiramdam Mobili more the patient will
ko.” as ver ty permanent be able to
balized by relate problem. Most perform
the client d to disease and physical Was the client
Neuro rehabilitative activity able to
Objective: musc states involve independently perform
-reduced ular some degree or with physical
amount of impai of immobility assistive activity
movement/ rment (e.g., as seen devices as independently?
activity in strokes, leg needed. Met___
-weak in fracture, Unmet___
appearance trauma, Assess for Partially
- Slurry morbid Objective: impediments Identifying the met___
Speech obesity, and to mobility specific cause
multiple a. After nursing (see Related (e.g., chronic
Measurem sclerosis). intervention, Factors in this arthritis versus
ent: With the the client will care plan). stroke versus
BP=140/90 longer life be able to be chronic
mmHg expectancy free of neurological
T= 36.3C for most complications disease) guides
RR= 22 Americans, of immobility, design of optimal
PR= 82 the incidence as evidenced treatment plan.
of disease by intact skin, Assess
and disability absence of patient’s
continues to thrombophlebiti ability to
grow. And s, and normal perform ADLs Restricted
with shorter bowel pattern. effectively movement affects
hospital and safely on the ability to
stays, a daily basis. perform most
patients are
being ADLs. Safety with
transferred to Suggested ambulation is an
rehabilitation Code for important
facilities or Functional concern.
sent home for Level
physical Classificatio
therapy in the n
home 0 Completel
environment. y
independent
Mobility is 1 Requires
also related use of
to body equipment or
changes from device
aging. Loss of 2 Requires
muscle mass, help from
reduction in another
muscle person for
strength and assistance,
function, supervision,
stiffer and or teaching
less mobile 3 Requires
joints, and help from
gait changes another
affecting person and
balance can equipment or
significantly device
compromise 4 Is
the mobility dependent,
of elderly does not Even patients
patients. participate in who are
Mobility is activity. temporarily
paramount if immobile are at
elderly Assess patient risk for effects of
patients are or caregiver’s immobility such
 as skin
to maintain knowledge of breakdown,
any immobility muscle weakness,
independent and its thrombophlebitis,
living. implications. constipation,
Restricted pneumonia, and
movement depression.
affects the Bed rest or
performance immobility
of most promote clot
activities of Assess for formation.
daily living developing
(ADLs). thrombophleb
Elderly itis (e.g., calf
patients are pain,
also at Homans’ sign,
increased risk redness,
for the localized
complications swelling, and
of immobility. rise in
temperature).

Assess skin
integrity.
Check for
signs of
redness,
tissue
Pressure sores
ischemia
develop more
(especially
quickly in
over ears,
patients with a
shoulders,
nutritional deficit.
elbows,
Proper nutrition
sacrum, hips,
also provides
heels, ankles,
needed energy
and toes).
 for participating
Monitor input in an exercise or
and output rehabilitative
record and program.
nutritional
pattern.
Assess Immobility
nutritional promotes
needs as they constipation.
relate to
immobility
(e.g., possible
hypocalcemia
, negative
nitrogen
balance).

Assess
elimination
status (e.g.,
usual pattern,
present
patterns,
signs of
constipation).
--
Proper use of
Assess wheelchairs,
emotional canes, transfer
response to bars, and other
disability or assistance can
limitation. promote activity
and reduce
Evaluate need danger of falls.
for home
assistance Obstacles such as
(e.g., physical throw rugs,
therapy, children’s toys,
visiting and pets can
nurse). further impede
one’s ability to
Evaluate need ambulate safely.
for assistive
devices.— The longer the
patient remains
immobile the
greater the level
of debilitation
that will occur.
Evaluate the
safety of the
immediate
environment.
—

Encourage
and facilitate
early
ambulation
and other
ADLs when
possible.
Assist with
each initial
Mobility aids can
change:
increase level of
dangling,
mobility.
sitting in
chair,
 Patients may be
ambulation.-- reluctant to move
or initiate new
Facilitate activity due to a
transfer fear of falling.
training by
using
appropriate Hospital workers
assistance of and family
persons or caregivers are
devices when often in a hurry
transferring and do more for
patients to patients than
bed, chair, or needed, thereby
stretcher. slowing the
patient’s recovery
Encourage and reducing his
appropriate or her self-
use of esteem.
assistive
devices in the
home This promotes a
setting.-- safe environment.

Provide
positive This optimizes
reinforcement circulation to all
during tissues and
activity.— relieves pressure.

This prevents
footdrop and/or
Allow patient
excessive plantar
to perform
flexion or
tasks at his or
tightness.
her own rate.
Do not rush
patient.
Encourage
independent
activity as
able and
safe.--. This keeps heavy
bed linens off
Keep side feet.
rails up and
bed in low
position.--. Exercise
promotes
Turn and increased venous
position every return, prevents
2 hours or as stiffness, and
needed.— maintains muscle
strength and
endurance.

Maintain
limbs in Research
functional supports that
alignment strength training
(e.g., with and other forms
pillows, of exercise in
sandbags, older adults can
wedges, or preserve the
prefabricated ability to maintain
splints). independent
Support feet living status and
in dorsiflexed reduce risk of
position. falling.
Use bed This drains
cradle. bronchial tree.

Perform
passive or
active
assistive ROM
exercises to This prevents
all tissue
extremities.— breakdown.

Promote
These prevent
resistance
buildup of
training
secretions.
services.—

This increases
lung expansion.
Turn patient
Decreased chest
to prone or
excursions and
semiprone
stasis of
position once
secretions are
daily unless
associated with
contraindicat
immobility.
ed.-- Liquids optimize
hydration status
Use and prevent
prophylactic hardening of
antipressure stool.
devices as
appropriate.--

Clean, dry,
and
moisturize
skin as
needed.

Encourage
coughing and Proper nutrition is
deep- required to
breathing maintain
exercises. adequate energy
level.
Use suction
as needed.

Use incentive
spirometer.

Encourage
liquid intake
of 2000 to
3000 ml/day Antispasmodic
 medications may
unless reduce muscle
contraindicat spasms or
ed.-- spasticity that
interfere with
Initiate mobility.
supplemental
high-protein
feedings as These optimize
appropriate. patient’s limited
reserves.
If impairment
results from
obesity,
initiate
nutritional
counseling as
indicated.--

Set up a
bowel
program
(e.g.,
adequate
fluid, foods
high in bulk,
physical
activity, stool
softeners,
laxatives) as
needed.
Record bowel
activity level.

Administer
medications
as
appropriate.—

"No pain, no gain"

is not always
true!

Teach energy-
saving
techniques.--

Assist patient
in accepting
limitations.
A safe
Emphasize
environment is a
abilities.
prerequisite to
improved
Explain
mobility.
progressive
activity to
patient. Help
patient or
caregivers to
Physical
establish
therapists can
reasonable
provide
and
specialized
obtainable
services.
goals.

Instruct
patient or
caregivers
regarding
hazards of
immobility.
Emphasize
importance of
measures
such as
position
change, ROM,
coughing, and
exercises.

Reinforce
principles of
progressive
exercise,
emphasizing
that joints are
to be
exercised to
the point of
pain, not
beyond.--

Instruct
patient/family
regarding
need to make
home
environment
safe.--

Refer to
multidisciplin
ary health
team as
appropriate.--

Encourage
verbalization
of feelings,
strengths,
weaknesses,
and concerns.

Submitted by:
John Glenn Bianzon
BSN105 Group18