CUES
NURSING DIAGNOSIS
SCIENTIFIC BASIS
RATIONALE
EVALUATION
Impaired Objective physical cues: mobility related -received to prescribed patient lying movement on bed, restriction. awake, coherent, & responsive. With left leg elevated on pillow. -v/s: BP:130/80 mmHg T: 37.5C P: 60bpm R: 20cpm Physical exam: (+)edema on left leg.
Edema usually results from an imbalance of forces controlling fluid exchange, including an alteration in capillary hemodynamics favoring the retention of sodium and water by the kidneys and the movement of fluid from the vascular space into the interstitium. (www.aafp.org)
-Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebiti s, constipation, pneumonia, and depression. - appropriate measures will be implemented to prevent infections and complications. -To lessen swelling related to the buildup of fluid.
After 8 hours of rendering appropriate nursing interventions the patient was able: -Performs physical activity independently or with assistive devices as needed. But wasnt able to maintain mobility at possible level. Therefore: Goal was only half met.