NURSING DIAGNOSIS STATEMENT: Impaired physical mobility R/T prolonged bed rest AEB NURSING OUTCOMES INTERVENTIONS RATIONALES

Assessment focused on NSG DIAGNOSIS NOC: NIC: Pt has been 1. Assess pt for pain upon 1. Identifying barriers to mobility restricted to initial assessment and q4h guides design of an optimal bed rest per during shift. treatment plan. S.T. Goals: physicians Pt demonstrates use of 2. Assess pt ability to 2. Provides data on extent of any orders perform ROM to all joints physical problems and guides Pt has broken adaptive techniques that promote ambulation and upon initial assessment therapy. pelvis transferring by end of during shift. 3. Proper use of assistive devices shift. 3. Evaluate the need for can promote activity. assistive devices upon 4. Proper nutrition provides needed initial assessment during energy for ambulation, transfer shift. techniques, and participation in 4. Monitor pts nutritional rehabilitative program. Maslows Hierarchy status q4h during shift. 5. Promote a safe secure of Needs: 5. Evaluate safety of pts environment and may reduce risk immediate environment for falls Physiological upon initial assessment 6. Pts may be reluctant to move or and q4h during shift. initiate movement due to fear of 6. Provide positive falling. A positive approach reinforcement during allows learner to feel good about activity during shift. learning accomplishments. 7. Refer pt to PT/OT to 7. PT and OT can provide promote ambulation specialized services to promote during shift. effective mobility. 8. Help pt use trapeze and 8. To encourage independence in side rails q4h during shift. immobility. (Sparks Ralph, 2011)

EVALUATION

Goal met: pt demonstrated use of adaptive techniques that promote ambulation and transferring by end of shift.

L.T. Goal: Pt remains free from complications of immobility until pt regains mobility within the limits of pts disease process.

1. Turn and reposition pt q2h during shift. 2. Assess for development of thrombophlebitis (calf pain, redness, localized swelling, and warmth) q4h during shift. 3. Assess elimination status (usual pattern, sign of constipation) upon initial assessment and q4h during shift. 4. Perform measures to prevent skin breakdown (clean, dry, and moisturized skin; use pressure relieving devices as indicated by physician q4h during shift. 5. Encourage adequate fluid intake of 2L-3L/day unless contraindicated q4h during shift. 6. Educate pt on proper nutritional intake for adequate energy resources and metabolic requirements during shift. 7. Encourage coughing, deep breathing and use of incentive spirometer q4h during shift.

1. Prevent skin breakdown by relieving pressure. 2. Reduced activity or immobility affects peripheral circulation and can promote clot formation. 3. Reduced activity and immobility decreases gastrointestinal mobility. 4. Reduce skin breakdown. 5. Liquids optimize hydration status and prevent hardening of stool which causes constipation and/or fecal impaction. 6. Pt will need adequate, properly balanced intake of protein, carbs, fats, vitamins, and minerals to provide energy resources. 7. Decreased chest excursions and stasis of secretions are associated with immobility. Coughing and deep breathing prevent build up of secretions. Incentive spirometry increases lung expansion.