Custom Search

Impaired Physical Mobility - Nursing Care Plan


Nursing Diagnosis for Impaired Physical Mobility

Musculoskeletal System:

1. Risk for Injury (fall when ambulation)
related to:
  • limited endurance.
  • a decrease in muscle strength.
  • stiffness and joint pain.
  • orthostatic hypotension.

2. Impaired Physical Mobility (individuals have limitations on the ability to physically move independently)
related to:
  • decreased range of motion.
  • bed rest.
  • a decrease in muscle strength.
  • pain or discomfort.
characteristics:
  • Not able to move in bed and the environment, not able to move or ambulation.
  • Limitations on the movement of the joints.
  • Decreased muscle strength and control of the movement of which is restricted.


Cardiovascular System

1. Activity Intolerance
related to:
  • long-term bedrest,
  • general weakness,
  • imbalance between demand and supply of oxygen.
2. Ineffective Tissue perfusion
related to:
  • disorders of blood flow through the vein.
  • edema.


Respiratory System

1. Ineffective breathing pattern
related to:
  • decrease in lung expansion.
  • chest muscle atrophy.
  • administration of depressant agents (analgesics, sedatives).

2. Impaired gas exchange
related to:
  • Ineffective breathing pattern.
  • decline in lung development.
  • buildup of lung secretions.

3. Ineffective airway clearance
related to:
  • stasis of pulmonary secretions.
  • imprecision body position.


Metabolic and Nutritional Systems

1. Imbalanced Nutrition Less Than Body Requirements
related to:
  • intake is inadequate.
  • catabolism of muscle mass.

2. Imbalanced Nutrition More than Body Requirements
related to:
  • imbalance between intake with energy expenditure.



Urinary System

1. Risk for infection: urinary
related to:
  • stasis of urine,
  • obstruction of urine flow.


 Elimination System

1. Constipation
related to:
  • decrease in physical activity,
  • lack of privacy is maintained,
  • inadequate diet.


Integumentary System

1. Impaired skin integrity
relate to:
  • Limitations mobilization.
  • Skin surface pressure.
  • Frictional forces on the surface of the skin ..



Planning

Musculoskeletal system :
  • Muskuloskeltal maintain normal function.
  • Normal ROM in all joints.
  • Normal strength and muscle mass.
  • Actively participate in the activities.

Intervention:
  • Create a workout schedule ROM: active, passive and isotonic.
  • Encourage active participation remedy selfcare activities.
  • Bodyaligment good position.
  • Ambulation aids clients if they can or standing on the side of the bed.


Cardiovascular system
  • Minimal cardiovascular disorders, characterized by: a standard backflow; adequate vein (no edema, pain, inflammation, venous distention, skin perubahn)

Intervention:
  • Monitor vital signs.
  • Teach clients how and when should Valsalva maneuver.
  • Wear tights if possible.
  • Elevate the legs about 20 minutes every day.
  • Assess skin in depressed areas.
  • View and add also the musculoskeletal system interventions.

Respiratory system
  • Maintain normal respiratory function, characterized by clean breath sounds during auscultation, normal chest expansion, no chest pain, fever, chest muscle movement embolism and atelectasis.

Intervention:
  • Assess breath sounds and chest expansion every 8 hours.
  • Teach clients effective deep breathing and coughing.
  • Change the position every 2 hours, and ambulation if possible and place it on a chair.
  • Diagfragma abdominal breathing exercises.



Elimination System
  • Normal elimination pattern marked no less urine output 1500 ml, urine specific gravity from 1 to 1.025 acidic urine. There is no sign of retention / urinary infection.
  • Shaped and soft stool, bowel movement over 2-3 days.

Intervention:
  • Monitor the color, density, total acidity of urine, feces color and characteristics, frequency of defecation.
  • Diet: increase in protein, calories, fiber.
  • Vitamin and mineral supplements.
  • Parenteral and enteral supplements.
  • Early ambulation and ROM exercises.

Related Articles :

No comments:

Post a Comment

IT News