N-impaired Physical Mobility 1na5q

NCM104b Cues Subjective: “Ang hirap ng may ganito (traction). Bawal kumilos, hindi man lang ako makapunta sa banyo para maligo. Hinihintay ko pa na may bisita ako para lang makapaglinis ng sarili ko” verbalized by the client. Objective: • Client is on modified buck’s extension traction. • Client is on semifowler’s position. • Client had fracture on the proximal 3rd of his left femur due to gunshot. • Client had three gunshots on his abdomen with mainly his duodenum and jejunum as well as in his right leg. • Provisional Diagnosis: Hypovolemic shock 2° to multiple GSW Measurement: • Red Blood Cells 3.77 x 10^12/L

BSN220/Group 80 Nursing Diagnosis Impaired Physical Mobility related to musculoskeletal impairment possibly evidenced by inability to move purposefully within the physical environment, imposed restriction.

Analysis

Planning

Impaired Physical Mobility Limitation in independent, purposeful physical movement of the body or of one or more extremities. (Nurse’s Pocket Guide-Diagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary s Moorhouse, Alice C. Murr p.457)

Goals: After 8 hours of nursing intervention, the client will be able to verbalize understanding of situation and individual treatment regimen and safety measures independently.

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation

Objectives: After 1 hour of nursing intervention, the client will be able to: 1. To identify at least five out of eight causative/contributing factors

Intervention

Rationale

Evaluation The goal was met.

Determine diagnosis that contributes to immobility

These conditions can cause physiological and psychological problems that can seriously impact physical, social, and economic well-being.

Note factors affecting current situation and potential time involved.

Identifies potential impairments and determines type of interventions needed to provide for client’s safety

Assess client’s developmental level, motor skills, ease and capability of movement, posture and gait.

To determine presence of characteristics of client’s unique impairment and to guide choice of interventions

Note older client’s general health status

Identified mobility as the most important functional ability that determines the degree of independence and healthcare needs among older persons.2 While aging per se does not cause impaired mobility, several

Met. The client was able to identify five out of eight causative/contributing factors.

Normal Findings: (Males) 5.5-6.5 x10^12/L • Hemoglobin 11.80 g/dL Normal Findings: (Males) 14-16 g/dL • Hematocrit 0.33 L/L Normal Findings: (Males) 0.42-0.52 L/L • Lymphocytes 0.21 Normal Findings: 0.25-0.35 • Eosinophils 0.01 Normal Findings 0.03-0.05

predisposing factors in addition to age-related changes can lead to immobility

facilities or sent home for physical therapy in the home environment. Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile ts, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment. (Nursing Care Plans: Nursing Diagnosis and Intervention by Gulanick, Myers,

2. To report three out of five of his functional ability

Evaluate for presence/degree of pain, listening to client’s description about manner in which pain limits mobility.

To determine needed interventions for pain management

Ascertain client’s perception of activity/exercise needs and impact of current situation. Identify cultural beliefs and expectations affecting recovery/response to long-term limitations.

Helps to determine client’s expectations/beliefs related to activity and potential long-term effect of current immobility. Also identifies barriers that may be addressed

Assess nutritional status and client’s report of energy level.

Deficiencies in nutrients and water, electrolytes and minerals can negatively affect energy and activity tolerance.

Determine history of falls and relatedness to current situation.

Client may be restricting activity because of weakness/debilitation, actual injury during a fall, or from psychological distress that can persist after a fall.

Determine degree of immobility in relation to 0–4 scale, noting muscle strength and tone, t mobility, cardiovascular status, balance, and endurance.

Identifies strengths and deficits impaired physical mobility and may provide information regarding potential for recovery

Determine degree of perceptual/cognitive impairment and ability to follow directions

Impairments related to age, chronic or acute disease condition, trauma,

Met. The client was able to report three out of five of his functional ability.

surgery, or medications require alternative interventions or changes in plan of care.

Klop, Galanes, Gradishar and Puzas)

3. To explain at least five of the optimal level of function and measures on how to prevent complications.

Observe movement when client is unaware of observation

To note any incongruence with reports of abilities.

Note emotional/behavioral responses to problems of immobility

Can negatively affect selfconcept 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

Determine presence of complications related to immobility

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

Assist with treatment of underlying condition(s)

To maximize potential for mobility and optimal function.

Discuss discrepancies in movement with client aware and unaware of observation and methods for dealing with identified problems.

May be necessary when client is using avoidance or controlling behavior, or is not aware of own abilities due to anxiety/fear.

Assist/have client reposition self

To enhance circulation to

Met. The client was able to explain at least five of the optimal level of function and measures on how to prevent complications.

on a regular schedule as dictated by individual situation

tissues, reduce risk of tissue ischemia.

Review/encourage use of proper body mechanics

To prevent injury to client and caregiver

Demonstrate/assist with use of side rails, overhead trapeze, roller pads, hydraulic lifts/chairs

For position changes/transfers. Instruct in safe use of walker/cane for ambulation.

affected body parts/ts using pillows/rolls, foot s/shoes, gel pads, etc.,

To maintain position of function and reduce risk of pressure ulcers.

Provide/recommend egg-crate, alternating air-pressure, or water mattress.

Reduces tissue pressure and aids in maximizing cellular perfusion to prevent dermal injury.

Use padding and positioning devices

To prevent stress on tissues and reduce potential for disuse complications.

Encourage client’s participation in self-care activities, physical/occupational therapies as well as diversional/recreational activities.

Reduces sensory deprivation, enhances selfconcept and sense of independence, and improves body strength and function.

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

To reduce fatigue.

Avoid routinely assisting or doing for client those activities that client can do for self.

Caregivers can contribute to impaired mobility by being overprotective or helping too much.

Identify/encourage energyconserving techniques for

Limits fatigue, maximizing

ADLs. Note change in strength to do more or less self-care

ister 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 program.

Assist client/SO to learn safety 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 to give return demonstration May need referral for and community services to provide care, supervision, companionship, respite services, nutritional and ADL assistance, adaptive devices or changes to living environment, financial assistance, etc

Met. The client was able to discuss four out of five of wellness program.

Demonstrate use of standing aids and mobility devices and have client/careprovider demostrate knowledge about/safe use of device. Identify appropriate resources for obtaining and maintaining appliances/ equipment.

Safe use of mobility aids promotes client’s independence and enhances quality of life and safety for client and caregiver (Nurse’s Pocket GuideDiagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary s Moorhouse, Alice C. Murr p.458-461)