Student Name: Marvin Berueda

Date Submitted: 11/10/15

Nursing Diagnosis: Impaired Mobility
Related to: Surgical procedure done on both Lower extremities; pain; anxiety
As manifested by: inability to stand up and walk around; limited ROM and reluctance to attempt
movement

Scientific Rationale: Patients surgical procedure on both lower extremities created pain and impaired
patients ability to ambulate freely.
Outcomes
Interventions
Rationale
Evaluation
1.
This
promotes
a
(measurable)
1. Create a safe
1. Patient was safe throughout the
safe and secure
environment for
shift. She did not experience any
environment. It
Short Term
patient.
of fall or other injury.
reduces
falls
and
the
Patient will be free of 2. Assess ability to
possibility of further
complications of
perform ROM
2. Patient expressed pain with an
complications.
immobility as
3. Assess skin
movement at first. Once she was
2. Assessing her
evidence by no
integrity
sitting up we were able to see her
ROM gives us a
injury, intact skin,
4. Monitor
few leg extensions with the help f
baseline of her
normal bowel pattern Nutritional Intake
her parents. Patient is able to slig
abilities to move.
and absence of
5. Provide positive
extend her leg but not at ninety
Doing ROM also
thrombophlebitis
reinforcement
allows venous return degrees.
and promotes
during activity
perfusion.
3. Skin was intact upon assessme
3. Skin integrity could Patient was able to sit in wheelch
be a complication
comfortably which repositions the
from staying in one
from when she was lying in bed.
position all day.
Constant monitoring
of the skin prevents
the risk of skin
breakdown
4. Proper nutrition
provides the energy
for ambulation,
provides nutrients for
recovery, and also
helps prevent
pressure ulcers from
forming
5. My patient may be
in pain but her
anxiety heightens
that pain. It is
important to reassure
her that she is doing
well in her

4. Patient was eating well. IV fluid

were stopped and patient was ab
eat breakfast and lunch.

5. During PT, patient felt like she w

going to fall over. Constant
reassurance that we were going t
keep her safe allowed her to sit u
do her ROM. Positive reinforceme
from her parents also helped.

progression. It also
allows her to feel
accomplished which
is important
according to
Eriksons
psychosocial theory.
Discouragement can
hinder the recovery
process.

Long Term
Patient will have
increased ROM and
have ability to bear
weight and walk
without pain.

Reference: Gulanick, M., & Myers, J.L. (2011). Nursing care plans: Nursing diagnoses,
interventions and outcomes, (7th ed.). St Louis: Mosby.