NCM104b BSN220/Group 80

Cues Nursing Analysis Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Impaired Impaired Physical Goals: The goal was met.
“Ang hirap ng may Physical Mobility Mobility After 8 hours of nursing
ganito (traction). related to Limitation in intervention, the client
Bawal kumilos, independent, will be able to verbalize
musculoskeletal
hindi man lang ako purposeful physical understanding of
makapunta sa impairment movement of the situation and individual
banyo para maligo. possibly evidenced body or of one or treatment regimen and
Hinihintay ko pa na by inability to more extremities. safety measures
may bisita ako para move purposefully (Nurse’s Pocket independently.
lang makapaglinis within the physical Guide-Diagnoses,
ng sarili ko” environment, Prioritized Objectives:
verbalized by the Interventions, and After 1 hour of nursing
imposed
client. Rationales by intervention, the client
restriction. Marilynn E. will be able to:
Objective: Doenges, Mary 1. To identify at least Determine diagnosis that These conditions can Met. The client was
• Client is on Frances Moorhouse, five out of eight contributes to immobility cause physiological and able to identify five out
modified buck’s Alice C. Murr causative/contributing psychological problems of eight
extension p.457) factors that can seriously impact causative/contributing
traction. physical, social, and factors.
• Client is on semi- Alteration in mobility economic well-being.
fowler’s position. may be a temporary
• Client had or more permanent Note factors affecting Identifies potential
fracture on the problem. Most current situation and impairments and
proximal 3rd of disease and potential time involved. determines type of
his left femur due rehabilitative states interventions needed to
to gunshot. involve some degree provide for client’s safety
• Client had three of immobility (e.g.,
gunshots on his as seen in strokes, leg Assess client’s To determine presence of
abdomen with fracture, trauma, developmental level, characteristics of client’s
mainly his morbid obesity, and motor skills, ease and unique impairment and to
duodenum and multiple sclerosis). capability of movement, guide
jejunum as well With the longer life posture and gait. choice of interventions
as in his right leg. expectancy for most
Americans, the Note older client’s Identified mobility as the
• Provisional general health status most important functional
Diagnosis: incidence of disease
and disability ability that determines the
Hypovolemic degree of independence
shock 2° to continues to grow.
And with shorter and healthcare needs
multiple GSW among older persons.2
hospital stays,
patients are being While aging per se does
Measurement:
transferred to not cause impaired
• Red Blood Cells
rehabilitation mobility, several
3.77 x 10^12/L
Normal Findings: predisposing factors
(Males) 5.5-6.5 facilities or sent home in addition to age-related changes
x10^12/L for physical therapy can lead to immobility
• Hemoglobin in the home
11.80 g/dL environment. Evaluate for To determine needed interventions
Normal Findings: presence/degree of pain, for pain management
(Males) 14-16 g/dL Mobility is also listening to client’s
• Hematocrit related to body description about manner
0.33 L/L changes from aging. in which pain limits
Normal Findings: Loss of muscle mass, mobility.
(Males) 0.42-0.52 reduction in muscle
L/L strength and function, Ascertain client’s Helps to determine client’s
• Lymphocytes stiffer and less mobile perception of expectations/beliefs
0.21 joints, and gait activity/exercise needs related to activity and
Normal Findings: changes affecting and impact of current potential long-term
0.25-0.35 balance can situation. effect of current immobility. Also
• Eosinophils significantly Identify cultural beliefs identifies barriers that may be
0.01 compromise the and expectations addressed
Normal Findings mobility of elderly affecting
0.03-0.05 patients. Mobility is recovery/response to
paramount if elderly long-term limitations.
patients are to
maintain any Assess nutritional status and Deficiencies in nutrients
independent living. client’s report of energy level. and
Restricted movement water, electrolytes and minerals
affects the can negatively affect energy and
performance of most activity tolerance.
activities of daily
living (ADLs). Determine history of falls and Client may be restricting
Elderly patients are relatedness to current situation. activity because of
also at increased risk weakness/debilitation,
for the complications actual injury during a fall,
of immobility. or from psychological
Nursing goals are to distress that can persist after a fall.
maintain functional
ability, prevent 2. To report three out of Determine degree of Identifies strengths and Met. The client was
additional impairment five of his functional immobility in relation to deficits able to report three out
of physical activity, ability 0–4 scale, noting muscle impaired physical mobility of five of his functional
and ensure a safe strength and tone, and may provide ability.
environment. joint mobility, cardiovascular information regarding
status, balance, and endurance. potential for recovery
(Nursing Care Determine degree of
Plans: Nursing perceptual/cognitive impairment Impairments related to
Diagnosis and and ability to follow directions age, chronic or acute
Intervention by disease condition, trauma,
Gulanick, Myers,

Klop, Galanes,
Gradishar and
Puzas)
Observe movement when client
is unaware of observation
Note emotional/behavioral
responses to problems of
immobility
Determine presence of
complications related to
immobility
3. To explain at least Assist with treatment of
five of the optimal underlying condition(s)
level of function and
measures on how to
prevent Discuss discrepancies in
complications. movement with client
aware and unaware of
observation and
methods for dealing with
identified problems.
Assist/have client reposition self
surgery, or medications
require alternative
interventions or changes in
plan of care.
To note any incongruence
with
reports of abilities.
Can negatively affect self-
concept and self-esteem,
autonomy, and
independence. Feelings of
frustration and
powerlessness may
impede 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
day of rest and
immobility.5 Other
complications include
changes in circulation and
impairments of organ
function affecting the
whole person
To maximize potential for Met. The client was
mobility and optimal able to explain at least
function. five of the optimal level
of function and
May be necessary when measures on how to
client is using avoidance prevent complications.
or controlling behavior, or
is not aware of own
abilities due to
anxiety/fear.
To enhance circulation to
on a regular schedule as dictated tissues, reduce risk of
by individual situation tissue ischemia.

Review/encourage use of proper To prevent injury to client and

body mechanics caregiver

Demonstrate/assist with use of For position changes/transfers.

side rails, overhead trapeze, roller Instruct in safe use of walker/cane
pads, hydraulic lifts/chairs for ambulation.

Support affected body To maintain position of function

parts/joints using pillows/rolls, and reduce risk of pressure ulcers.
foot supports/shoes, gel pads, etc.,

Provide/recommend egg-crate, Reduces tissue

alternating air-pressure, or water pressure and aids in maximizing
mattress. cellular perfusion to prevent dermal
injury.

Use padding and positioning To prevent stress on

devices tissues and reduce
potential for
disuse complications.

Encourage client’s Reduces sensory

participation in self-care
activities,
physical/occupational
therapies as well as
diversional/recreational
activities.
deprivation, enhances self-
concept
and sense of independence, and
improves body strength and
function.

Provide client with To reduce fatigue.

ample time to perform
mobility-related tasks.
Schedule activities with
adequate rest periods during the
day

Avoid routinely assisting or Caregivers

doing for client those activities can contribute to impaired mobility
that client can do for self. by being overprotective or helping
too much.

Identify/encourage energy- Limits fatigue,

conserving techniques for maximizing
 ADLs.
Note change in strength to do
more or less self-care
Administer medications before
activity as needed for pain relief
Perform/encourage regular skin
examination and care
Encourage adequate intake of
fluids/nutritious foods
Encourage client’s/SO’s
involvement in decision making
as much as possible
Discuss safe ways that client can
exercise
4. To discuss four out of
five of wellness Assist client/SO to learn safety
program. measures as individually
indicated.
Involve client and SO(s)
in care, assisting them to
learn ways of managing
problems of
immobility, especially when
impairment is expected to be
long-term.
participation.
To promote psychological
and physical benefits of
self-care and to adjust
level of assistance
as indicated.
To permit maximal
effort/involvement in activity.
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.
Multiple options provide client
choices and variety
May need instruction and Met. The client was
to able to discuss four out
give return demonstration of five of wellness
program.
May need referral for
support and community
services to provide care,
supervision,
companionship, respite
services,
nutritional and ADL
assistance, adaptive
devices or changes to
living environment,
financial
assistance, etc
 Safe use of mobility aids
Demonstrate use of promotes client’s
standing aids and independence and
mobility devices and enhances quality of
have client/careprovider life and safety for client and
demostrate knowledge caregiver
about/safe (Nurse’s Pocket Guide-
use of device. Identify Diagnoses, Prioritized
appropriate resources for Interventions, and
obtaining and Rationales by Marilynn
maintaining appliances/ E. Doenges, Mary
equipment. Frances Moorhouse,
Alice C. Murr p.458-461)