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Patient:N.T. Age: 64 years old Gender: Female
Chief Complaints: Left sided weakness Admitting Diagnosis: Cardiovascular disease (CVD), probably cardio-embolism
Assessment Nursing
Diagnosis
Rationale Desired
Outcomes
Nursing Interventions Justifications Evaluation
Actual/
Abnormal cues
FunctionalLevel
Classification:
3 (Requires
help from
another person
and equipment
device)
Muscle
strength of 2/5
score (muscle
can contract
but cannot
move the body
part fully
against gravity)
Assisted with
hourly turning
to different
positions.
Facial mask of
pain when
Impaired
physical mobility
of the upper and
lower extremitiesr/t
neuromuscular
skeletal
impairment as
evidence by
limitation in
moving, decrease
muscle strength,
and assisted when
turning and
moving.
Definition:
Limitation in
independent,
purposeful
physical
movement of the
body or of one or
more extremities
Source:
Doenges, M.E, et.
Al. Nurses
Precipitating
Factors:
- Sedentarylifestyle
-(+) Diabetes
Mellitus
Predisposing
Factors:
- Age: 64 yearsold
-Gender
(menopausal
period)
Fatty deposits migrate into the blood
vessels clump up and aggravated by
viscous blood due to DM
Arteriosclerosis and atherosclerosis
will occur causing thrombus
formation
Thrombus becomes bigger
associated also with blood
components (RBC, platelets) which
precipitates to pile up
Thrombus breaks away from the its
attachment and become a free
After 3 days of
nursing
interventions,
the patient willbe able to:
1.)Demonstrate
techniques or
behaviors that
enable
resumption of
activities
Independent and
Collaborative Nursing
Interventions
1.1 Assess degree of
immobility produced by
injury/treatment.
1.2 Encourage
participation in
diversional/ recreational
activities. Maintain
stimulating
environment, e.g., radio,
TV, newspapers,
personal
possessions/pictures,
clock, calendar, visits
from family/friends.
1.3 Encourage use of
isometric exercisesstarting with the
unaffected limb.
Independent and
Collaborative Nursing
Interventions
1.1 To initiate proper care
and be able to assist in some
part of the patients ADLs
1.2 Provides opportunity for
release of energy, refocuses
attention, enhances patients
sense of self-control/self-
worth, and aids in reducing
social isolation.
1.3 Isometrics contract
muscles without bendingjoints or moving limbs and
help maintain muscle
strength and mass. Note:
After 3 days of
nursing intervent
the patient was a
1.)Goal partially
demonstrated par
in meeting basic
by cooperating w
the student nurse
well to other hea
care team by doin
ADLs.
7/27/2019 NCP-Impaired physical mobility.doc
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turning the
patient
Weakness and
limitation in
motion of body
parts
Limited rangeof motion
Strengths:
Strong family
support
Good
compliance totreatment and
medications
Pocket Guide
Edition 11. F.A.
Davis Company.
Philadelphia,
Pennsylvania.
2008.
moving emboli
Embolus will travel to the blood
vessel pathways going to the heart
and lodge within the narrow blood
vessel
Impairment of blood supply in the
heart causing deterioration and
deprived of oxygenation and
nutrients (such as the brain)
Brain cells compensate with the lack
of viable products needed for its
stability
Further, brain deteriorates slowly
causing neurologic and muscular
impairment
Peripheral nerves (those in the
extremities) will gradually lose its
functionality
Impaired physical mobility of the
2.)Participate
in ADLs and
desired
activities
3.) Maintain
position of
function and
skin integrity
as
evidenced by
absence of
contractures,
footdrop,
decubitus, and
so forth.
2.1 Instruct patient
in/assist with
active/passive ROM
exercises of affected and
unaffected extremities.
2.2 Assist
with/encourage self-care
activities (e.g., bathing,
shaving).
3.1 Provide footboard,
wrist splints,
trochanter/hand rolls as
appropriate.
3.2 Reposition
periodically every 2
hours and encourage
coughing/deep-
breathing exercises.
3.3 Auscultate bowel
sounds. Monitor
elimination habits and
These exercises are
contraindicated while acute
bleeding/edema is present.
2.1 Increases blood flow to
muscles and bone to
improve muscle tone,
maintain joint mobility;
prevent contractures/atrophy
and calcium resorption from
disuse
2.2 Improves muscle
strength and circulation,
enhances patient control in
situation, and promotes self-
directed wellness.
3.1 Useful in maintaining
functional position of
extremities, hands/feet, and
preventing complications
(e.g., contractures/footdrop).
3.2 Prevents/reduces
incidence of skin and
respiratory complications
(e.g., decubitus,
atelectasis, pneumonia).
3.3 Bed rest, use of
analgesics, and changes in
dietary habits can slow
2.)Goal partially
participated in th
activites conduct
the student nurse
as frequent turnin
every 2 hours,
allowing to have
oral care, respon
by nodding in clo
ended questions
patient have diffi
in uttering words
3).Goal partially
Maintained posit
and function of s
integrity by not
manifesting any
signs of skin
impairment.
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upper and lower extremities
Source: Medical-Surgical Book
Edition 16 by Williams and
Wilkins.
provide for regular
bowel routine. Place on
bedside commode, if
feasible, or use fracture
pan. Provide privacy.
3.4 Work hand in hand
with other allied health
care team in maintaining
patients treatment and
functionality
peristalsis and produce
constipation. Nursing
measures that facilitate
elimination may
prevent/limit complications.
Fracture pan limits flexion
of hips and lessens pressure
on lumbar region/lower
extremity cast.
3.4 Creates positive
assurance in maintaining the
quality of care and update
the current status of the
patient.
Recommended