Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Immobility related to Short term goal: Independent: After nursing

“Kita niyo naman, di prolonged bed rest > after 2 hrs of nursing intervention, Goal
na siya and limited strength intervention The * Assess for *Even patients who are was met.
makagalaw...” secondary to present patient: impediments to temporarily immobile are
As verbalized by illness. mobility at risk for effects of after 2 hrs of
client’s wife Performs physical immobility such as skin nursing intervention
Rationale: activity with * Assess patient or breakdown, muscle The patient
assistance caregiver’s knowledge weakness,
Objective: Limitation in of immobility and its thrombophlebitis, Performed physical
independent, implications. constipation, pneumonia, activity with
Inability to move purposeful physical Long Term goal : and depression. assistance and
purposefully within movement of the > after 1 week of assistive devices
the physical body or of one or nursing intervention *Pressure sores develop devices
environment, more extremities patient will remain * Assess skin integrity. more quickly in patients
including bed free of complications Check for signs of with a nutritional deficit.
motility, transfers Alteration in of immobility as redness, tissue ischemia Proper nutrition also
and ambulation mobility may be a evidenced by intact (especially over ears, provides needed energy
temporary or more skin, absence of shoulders, elbows, for participating in an Long term goal:
Limited ROM permanent problem. thrombophlebitis and sacrum, hips, heels, exercise After 1 week of
Most disease and normal bowel pattern. ankles, and toes). nursing intervention
Decreased muscle rehabilitative states *Pressure sores develop patient remained
endurance, strength, involve some degree * Monitor input and more quickly in patients free of
control or mass of immobility output record and with a nutritional deficit. complications of
nutritional pattern. Proper nutrition also immobility as
Functional level Mobility is also Assess nutritional needs provides needed energy evidenced by intact
class: 4 (dependent, related to body as they relate to for participating in an skin, absence of
does not participate changes from aging. immobility (e.g., exercise thrombophlebitis
in activity, requires Loss of muscle mass, possible hypocalcemia, and normal bowel
help from another reduction in muscle negative nitrogen *Immobility promotes pattern
person and strength and balance). constipation.
equipment or device function, stiffer and
ie: wheelchair less mobile joints, * Assess elimination
and gait changes status (e.g., usual
Age: 74 years old affecting balance can pattern, present *The longer the patient
BP: significantly patterns, and signs of remains immobile the
compromise the constipation). greater the level of
mobility of elderly debilitation that will
patients. Mobility is Evaluate need for occur.
paramount if elderly assistive devices.
patients are to Proper use of
maintain any wheelchairs, canes,
independent living. transfer bars, and other
Restricted movement assistance can promote
affects the activity and reduce
performance of most danger of falls.
activities of daily
living (ADLs). * Evaluate the safety of
Elderly patients are the immediate
also at increased risk environment. Obstacles
for the complications such as throw rugs,
of immobility. children’s toys, and pets *Mobility aids can
can further impede increase level of
one’s ability to mobility.
ambulate safely.

* Encourage and
facilitate early *This promotes a safe
ambulation and other environment.
ADLs when possible.
Assist with each initial
change: dangling, *This optimizes
sitting in chair, circulation to all tissues
ambulation. and relieves pressure.
* Facilitate transfer *This prevents footdrop
training by using and/or excessive plantar
appropriate assistance flexion or tightness.
of persons or devices Support feet in
when transferring dorsiflexed position.
patients to bed, chair, or
stretcher. *Decreased chest
excursions and stasis of
* Keep side rails up and secretions are associated
bed in low position. with immobility.

* Turn and position

every 2 hours or as
needed.

* Maintain limbs in
functional alignment
(e.g., with pillows,
sandbags, wedges, or
prefabricated splints).

* Perform passive or
active assistive ROM
exercises to all *Liquids optimize
extremities. Exercise hydration status and
promotes increased prevent hardening of
venous return, prevents stool.
stiffness, and maintains
muscle strength and
endurance.

* Turn patient to prone

or semiprone position
once daily unless
contraindicated. This
drains bronchial tree.

Clean, dry, and

moisturize skin as *To promote safety
needed.

* Encourage coughing
and deep-breathing
exercises. These
prevent buildup of
secretions. *This increases lung
expansion.
* Encourage liquid
intake of 2000 to 3000 *Antispasmodic
ml/day unless medications may reduce
contraindicated. muscle spasms or
. spasticity that interferes
* Set up a bowel with mobility.
program (e.g., adequate
fluid, foods high in
bulk, physical activity)
as needed. Record
bowel activity level.

* Instruct patient or
caregivers regarding
hazards of immobility.
Emphasize importance
of measures such as
position change, ROM,
coughing, and
exercises.

* Instruct patient/family
regarding need to make
home environment safe.
A safe environment is a
prerequisite to
improved mobility.

Dependent:

* Use incentive
spirometer as indicated.

* Administer
medications as
appropriate. (i.e.
Antispasmodic
medications)