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.
- 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.
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.
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