Impaired physical mobility may be related to diminished strength and endurance due to diminished energy intake. After 8 hours of medical and nursing interventions, the client will be able to: 1) Demonstrate improvement in spontaneous movements. Goals of care include: Assess muscle tone, strength, mass; joint mobility, pain, stiffness, swelling; ability to move. Provide quiet play and progress in ambulation by scheduling dangling at bedside, standing with support, ambulation with support with increase daily.
Impaired physical mobility may be related to diminished strength and endurance due to diminished energy intake. After 8 hours of medical and nursing interventions, the client will be able to: 1) Demonstrate improvement in spontaneous movements. Goals of care include: Assess muscle tone, strength, mass; joint mobility, pain, stiffness, swelling; ability to move. Provide quiet play and progress in ambulation by scheduling dangling at bedside, standing with support, ambulation with support with increase daily.
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Impaired physical mobility may be related to diminished strength and endurance due to diminished energy intake. After 8 hours of medical and nursing interventions, the client will be able to: 1) Demonstrate improvement in spontaneous movements. Goals of care include: Assess muscle tone, strength, mass; joint mobility, pain, stiffness, swelling; ability to move. Provide quiet play and progress in ambulation by scheduling dangling at bedside, standing with support, ambulation with support with increase daily.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
Nursing Diagnosis: Impaired Physical Mobility may be related to decreased strength and endurance due to diminished energy
intake as manifested by:
a. weak spontaneous movements
b. Extremities in some degree of flexion when restraints are removed c. with poor muscle tone, loose ligaments
Goals of Care Nursing Interventions Rationale Client’s Response
After 8 hours of medical and Independent: nursing interventions, the client will be able to: Assessment:
1) Demonstrate improvement • Assess muscle tone, • Provide information • Client demonstrates
in spontaneous strength, mass; joint about musculoskeletal weak spontaneous movements. mobility, pain, stiffness, condition and function. movement. swelling; ability to move. • Maintain stress during acute stages to promote • Client’s arms were • Assess bed rest status, healing and restoration restrained to protect his activity restrictions, and of health. intravenous line. imposed immobility by • braces, casts, traction, splints. • Prevents complications of immobility by • Assess physical effects monitoring and of immobilization on intervening when body systems; needed; mobility constipation, skin provides important breakdown, urinary contributions to retention, development and hypercalcemia, loss of physical health. muscle strength, contractures, circulatory stasis, stasis of pulmonary secretions, anorexia, renal calculi, decreased metabolism and energy, loss of nerve innervation. • Client always stays on the bed. • Maintains large and small muscle strength Therapeutics: as condition permits.
• Provide quiet play and
progress in ambulation by scheduling dangling at bedside, standing with • Client is on a supine support, ambulation with position and placed on support with increase daily • Prevents fatigue and his crib. Health care and praise for all attempts conserves energy. team let the baby sleep regardless of progress. by minimizing their contact on the baby. • Coordinate rest with periods of mobility. • Client is on the bed and • Promotes mobility his arms are restrained. according to limitation Health Teachings: of illness and provides outlet for frustration of • Encourage all age – imposed immobility. • Student nurse was not appropriate activities that able to teach the facilitate mobility, allow • Maintains muscle and mother because she infant to crawl. joint function. was not present at that time.
• Teach parents and child
range of motion, strengthening exercises as appropriate. • Prevents contractures • Client is maintained on Collaborative: and physical deformity a body alignment on and preserves joint bed rest. Therapeutic: function.
• Maintain body alignment • Any special shoes,
on bed rest, reposition splints or appliance every 2 hours or as • Maintains position at were not noted. needed. night and prevents deformity. • Apply special shoes, splint, or appliance for day or • Student nurse was not night use. able to reinforce the • Promotes compliance importance of therapy Health Teachings: with prescribed therapy to the mother because especially if needed to she was not present at • Reinforce parents and child ensure mobility or that time. of importance of therapy health maintenance in and follow – up care, short chronic disorders. or long – term depending • Student nurse was not on need. • Promotes compliance able to inform the with program to mother because she maintain mobility and was not present at that • Inform parents and child of understanding of effects time. hazards of immobility. of mobility.
General Evaluation:
After 8 hours of medical and nursing interventions, the client demonstrated weak spontaneous movement.