NCP-Impaired physical mobility.doc

7/27/2019 NCP-Impaired physical mobility.doc

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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.


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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.

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NCP-Impaired physical mobility.doc