NURSING CARE PLAN Nursing Diagnosis: Impaired Physical Mobility Related Factors: acute pain AEB client report of increased abdominal discomfort with movement. Diagnosis Definition: A limitation in independent, purposeful physical movement of the body or of one or more extremities. Identify the NANDA defining characteristics that your client exhibits: Difficulty turning Slowed movement Limited ROM Expected Outcome: (Format: Client will (timeline) AEB: (factors that prove the client statement was met) The client will have improved physical mobility during this 8 hour shift AEB: Client will ambulate 40 meters in the hall. Client will perform active upper and lower extremity ROM exercises while sitting in bed. Nursing Actions Nursing Assessments: (Actions that require gathering &/or monitoring of information) Assess mobility skills in the following order: (1) bed mobility; (2) transition movements such as sit to stand, sitting down, and transfers; and (3) standing and walking activities. Assess the client for the cause of impaired mobility. Determine whether cause is physical, psychological, or motivational. Monitor condition of skin condition covering bony prominences. Rationale for each Nursing Assessment: (if one rationale is meant for more than one assessment, indicate with numbering system) Assess for quality of movement, ability to walk and move, gait pattern, ADL function, presence of spasticity, activity tolerance, and activity order. (Ackley 550) Some clients choose not to move because of psychological factors such as fear of falling or pain; an inability to cope; or depression. (Ackley 550) Pressure ulcers usually occur over bony prominences, such as the sacrum, coccyx, trochanter, and heels, as a result of unrelieved pressure between the prominence and support surface. (Ackley 774) Independent Nursing Interventions: (Actions by the nurse that require care, teaching, or collaboration with other HCP’s; do not use dependent interventions) Encourage safe ambulation, with assisstance if necessary, of 40 meters in the hall. Instruct client in how to perform active ROM exercises using both upper and lower extremities at least once a day repeating each maneuver three times. Use the WALC Intervention (Walk; Address pain, fear, fatigue during exercise; Learn about exercise; Cue by self-modeling) to improve exercise adherence. Rationale for each Nursing Interventions: Ambulation prevents complications such as deep vein thrombosis and improves level of independence. (Ackley 551) These exercises help prevent weakening and atrophy of muscles. (Ackley 551) The WALC Intervention resulted in more exercise and had greater self-efficacy expectations regarding exercise. (Ackley 552) Process Evaluation: The client met the expected outcome completely □ partially □ not at all as evidenced by: (you must address each outcome AEB criteria and use the same order and numbering system as on outcome) The client did have improved physical mobility during this 8 hour shift AEB: Client ambulated from the bed to the shower with minimal assistance. Client did perform active upper and lower extremity ROM exercises while sitting in bed. Process Evaluation: Discuss the effectiveness of each independent intervention in assisting the client to meet the expected outcome: (again, use the same order and numbering system as interventions as the interventions) The client safely ambulated from the bed to the shower and stated that she did not feel like she needed assistance. The client demonstrated how to correctly perform upper and lower extremity ROM exercises and noted that she "did not have any more pain when I was moving." The WALC Intervention was not performed as I was not present when the client was ambulating to the shower. Disposition of the Plan of Care: I will continue □ modify □ terminate □ the nursing care plan as follows: The plan is working sufficiently and should be continued during hospitalization but I would increase active ROM exercise to two times per day and implement the WALC Intervention. Rationale for Disposition of Care: The interventions will prevent muscle atrophy, increase mobility and prepare the client for discharge.
Posted on: Tue, 24 Sep 2013 20:55:51 +0000