Nursing Care Plan: impaired bed Mobility Definition: Limitation of independent movement from one bed position to another

Related Factors

Neuromuscular or musculoskeletal impairment Insufficient muscle strength; deconditioning; obesity Environmental constraints (i.e., bed size and type, treatment equipment, restraints) Pain; sedating medications Deficient knowledge Cognitive impairment

Defining Characteristics Subjective

[Reported difficulty performing activities]

Objective

Impaired ability to: turn side to side; move from supine to sit- ting, sitting to supine; scoot or reposition self in bed; move from supine to prone, prone to supine; move from supine to long-sitting, long-sitting to supine

Desired Outcomes/Evaluation Criteria Client/Caregiver Will:

Verbalize willingness to participate in repositioning program. Verbalize understanding of situation and risk factors, individual therapeutic regimen, and safety measures. Demonstrate techniques and behaviors that enable safe repositioning. Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop, decubitus, and so forth. Maintain or increase strength and function of affected and/or compensatory body part.

Actions/Interventions 1. Determine diagnoses that contribute to immobility (e.g., MS, arthritis, Parkinsons disease, hemi-/para-/tetraplegia, fractures, multiple trauma, burns, head injury, depression, dementia). 2. Note individual risk factors and current situation, such as surgery, casts, amputation, traction, pain, age, general weakness or debilitation. 3. Determine degree of perceptual or cognitive impairment and/ or ability to follow directions. 4. Determine functional level classification 1 to 4 (1 requires use of equipment or device, 2 requires help from another person for assistance, 3 requires help from another person and equipment device, 4 dependent, does not participate in activity). 5. Note cognitive, emotional, or behavioral conditions or con- cerns impacting mobility.

6. Note presence of complications related to immobility. (Refer to ND Disuse Syndrome.) 7. Ascertain that dependent client is placed in best bed for situation (e.g., correct size, support surface, and mobility functions) Rationale: to promote mobility and enhance environmental safety. 8. Turn dependent client frequently, utilizing bed and mattress positioning settings to assist movements; reposition in good body alignment, using appropriate supports. 9. Instruct client and caregivers in methods of moving client relative to specific situations and mobility needs. 10. Observe skin for reddened areas or shearing injury. Provide appropriate pressure relief and surface support mattress Rationale: to reduce friction, maintain safe skin and tissue pressures, and wick away moisture. Provide regular skin care, as appropriate. 11. Assist on and off bedpan and into sitting position (or use cardioposition bed or footegress bed) Rationale: to facilitate elimination. 12. Administer medication prior to activity as needed for pain relief Rationale: to permit maximal effort and involvement in activity. 13. Observe for change in strength to do more or less self-care Rationale: to adjust care as indicated. 14. Assist with activities of hygiene, toileting, feeding, as indicated. 15. Provide diversional activities, as appropriate. 16. Ensure telephone and call bell is within reach Rationale: to promote safety and timely response. 17. Provide individually appropriate methods to communicatead equately with client. 18. Provide extremity protection (padding, exercises, etc.). 19. Include physical and occupational therapists and rehabilitation providers in creating movement program and identifying assistive devices. 20. Involve client/SO(s) in determining activity schedule. Rationale: Promotes commitment to plan, maximizing outcomes. 21. Encourage continuation of exercises Rationale: to maintain and enhance gains in strength and muscle control. 22. Obtain, or identify sources for, assistive devices. Demonstrate safe use and proper maintenance. Documentation Focus Assessment/Reassessment

Individual findings, including level of function, ability to participate in specific or desired activities.

Planning

Plan of care and who is involved in the planning.

Implementation/Evaluation

Responses to interventions, teaching, and actions performed.

Attainment or progress toward desired outcome(s). Modification to plan of care.

Discharge Planning

Discharge and long-term needs, noting who is responsible for each action to be taken. Specific referrals made. Sources for, and maintenance of, assistive devices.