- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Activity intolerance
- Perceptual or cognitive impairment
- Musculoskeletal impairment
- Neuromuscular impairment
- Medical restrictions
- Prolonged bed rest
- Limited strength
- Pain or discomfort
- Depression or severe anxiety
As evidenced by: [Check those that apply]
- Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation
- Reluctance to attempt movement
- Limited range of motion (ROM)
- Decreased muscle endurance, strength, control, or mass
- Imposed restrictions of movement, including mechanical, medical protocol, and impaired coordination
- Inability to perform action as instructed
Patient’s Diagnosis: –
Date:-
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- performs physical activity independently or with assistive devices as needed.
- be free of complications of immobility, as evidenced by: intact skin, absence of thrombophlebitis, and normal bowel pattern
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess for impediments to mobility. | Identifying the specific cause guides design of optimal treatment plan. |
| Assess patient's ability to perform ADLs effectively and safely on a daily basis. | Restricted movement affects the ability to perform most ADLs. Safety with ambulation is an important concern. |
| Assess patient or caregivers knowledge of immobility and its implications. | Even patients who are temporarily immobile are at risk for some of the effects of immobility, such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression). |
| Assess for developing thrombophlebitis (calf pain, Homans' sign, redness, localized swelling, and rise in temperature). | Bed rest or immobility promotes clot formation. |
| Assess elimination status. | Immobility promotes constipation. |
| Evaluate need for assistive devices. | Proper use of wheelchairs, canes, transfer bars, and other assistance can promote activity and reduce danger of falls. |
| Evaluate the safety of the immediate environment. | Obstacles such as throw rugs, children's toys, pets, and others can further impede one's ability to ambulate safely. |
| Encourage and facilitate early ambulation and other ADLs when possible. | The longer the patient remains immobile the greater the level of debilitation that will occur. |
| Encourage appropriate use of assistive devices in the home setting. | Mobility aids can increase level of mobility. |
| Provide positive reinforcement during activity. | Patients may be reluctant to move or initiate new activity from a fear of falling. |
| Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe. | Hospital workers and family caregivers are often in a hurry and do more for patients than needed, thereby slowing patient's recovery and reducing his or her self-esteem. |
| Keep side rails up and bed in low position. | To promote safe environment. |
| Turn and position every 2 hours, or as needed. | To optimize circulation to all tissues and to relieve pressure. |
| Maintain limbs in functional alignment (e.g., with pillows, sandbags, wedges, or prefabricated splints). | To prevent footdrop and/or excessive plantar flexion or tightness. |
| Support feet in dorsiflexed position (Use bed cradle) | To keep heavy bed linens off feet. |
| Perform passive or active assistive ROM exercises to all extremities | To promote increased venous return, prevent stiffness, and maintain muscle strength and endurance |
| Promote resistance training services. | Research supports that strength training and other forms of exercise in older adults can preserve the ability to maintain independent living status and reduce risk of falling. |
| Turn patient to prone or semiprone position once daily unless contraindicated. | To drain bronchial tree. |
| Use prophylactic antipressure devices as appropriate. | To prevent tissue breakdown. |
| Use incentive spirometer to increase lung expansion. | Decreased chest excursions, and stasis of secretions are associated with immobility. |
| Encourage liquid intake of 2000 to 3000 ml per day unless contraindicated. | To optimize hydration status and prevent hardening of stool. |
| Initiate supplemental high-protein feedings as appropriate. | Proper nutrition is required to maintain adequate energy level. |
| Administer medications as appropriate. | Antispasmotic medications may reduce muscle spasms or spasticity that interfere with mobility. |
| Teach energy saving techniques. | To optimize patient's limited reserves. |
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