NURSING CARE PLAN: IMPAIRED PHYSICAL MOBILITY ASSESSMENT EXPLANATION OF THE PROBLEM NURSING OBJECTIVES LTO: After 72 hours

of NURSING INTERVENTIONS RATIONALE EVALUATION

S> Nahihirapan akong gumalaw as verbalized by patient O>: initial vital signs of: T: BP: RR: PR: >needs assistance when ambulating >lower muscle tone of 2/5 >reports of weakness and difficulty ambulating NURSING DIAGNOSIS: Impaired Physical Mobilty related to

nursing interventions the patient will be able to manifest to signs of difficulty in mobilizing, able to walk or ambulate without any assistance. Does not need any assistive device in doing his activities of daily living STO: After 8 hours of nursing interventions the patient will be able to strengthen his muscle strength from 23 or 2-4, can ambulate but with assistance

Assess degree of immobility produced by injury/treatment and note patients perception of immobility

Patient maybe restricted by self-view/self perception out of proportion with actual physical limitations, requiring information/interventions to promote progress towards wellness Bed rest, use of analgesic and changes in dietary habits can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent/limit complication. fracture pan limits flexion of hips and lessens pressure on lumbar region/lower extremity cast

Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy

Monitor BP with resumption of activity. Note reports of dizziness

Postural hypotension is a common problem following prolonged bed rest and may require specific interventions like: (tilt table with gradual elevation to upright position)

NURSING CARE PLAN: IMPAIRED PHYSICAL MOBILITY

Provide footboard, wrists splints, trochanter/ handrolls as appropriate

Useful in functional position of of extremities,hand/feet and helps to maintain muscle strength and mass

Repostion periodically Prevents/reduces and encourage coughing incidence of skin and or deep breathing respiratory complications techniques (decubitus ulcer, atelectasis, pneumonia)

Place in supine position periodically if possible, when traction is used to stabilize the lower limb fracture

Reduces risk of flexion contracture of the hip

Initiate bowel program

To promote regular bowel elimination

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Assist with mobility by means of wheelchair, walker, crutches, canes as soon as possible

Early mobility reduces complications of bed rest, promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety Provides opportunity for release of energy, refocuses attention, enhances patients sense of self-control/self worth

Encourage participation in diversional/ recreational activities. Maintain stimulating environment like watching television, listening to the radio Instruct patient to do passive ROM activities of affected and unaffected etremity

Increases blood flow to he muscles and bone to improve muscle tone, maintain joint mobility, prevent contractures, atrophy, and calcium reabsorption from disuse Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation

Encourage patient to increase fluid intake at about 2000-3000ml/day

NURSING CARE PLAN: IMPAIRED PHYSICAL MOBILITY

Encourage patient on diet high in protein, carbohydrates, vitamins and minerals, limiting protein content until after 1st BM

In the presence of muskoloskeletal injuries, nutrients required for healing are rapidly depleted, often resulting to weight loss. Protein foods can increase contents in small bowel, resulting in gas formation and constipation. Therefore GI function should be restored before protein foods are increased

Encourage patient on isometric exercises starting with the unaffected limb.

Isometrics contract muscles without bending joints or moving the limbs and helps to maintain muscle strength and mass.