Nursing Assessment S> Okay na ngayon si nanay kumpara dati, ngayon naigagalaw na niya yung kaliwang kamay at paa

niya, pati mata niya naididilat-dilat na niya. As verbalized by the relative. O> Patient has edema on right hand, right knee, right leg and right foot, anthropometric measure on her triceps of 23 inches in circumference, patient often tries to remove her mechanical ventilator from her tracheostomy with her left hand, patient lifts her left knee at about 10-15 times every 2 mins. Patient cannot move from one bed position to another without assistance, muscle strength of 5/5 on left hand, 5/5 on left lower extremity, 0/5 on right upper and lower extremities.

Nursing Diagnosis Impaired Mobility r/t insufficient muscle strength as evidenced by muscle strength of 5/5 on left hand, 5/5 on left lower extremity, 0/5 on right upper and lower extremities.

Scientific Rationale Alteration in mobility may be a temporary or more permanent problem in the case of our patient due to her right sided body weakness she is not able to ambulate and mobilize. Since the patient is around 60 years old, loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients.

Plan Goal: After 24 hours of nursing intervention the nurse should be able to assess the ROM of the patient and be able to teach the active and passive, and other therapeutic exercises that can be done for the patient to prevent stiffness of the muscles such as foot drop and deconditioning of the clients muscles. Objective: After 8 hour of health teaching the clients relative and significant other should be able to perform passive and active exercises for the patient.

Intervention Independent: 1. Assist or have client reposition self on a regular basis. 2. Raise side rails at all times. 3.Assess barriers to participation in regimen

Scientific Rationale = To avoid or lessen the pressure sore. = For safety of the client. = Lack on information of both the significant other and the patient may cause harm to the patient. = Promotes wellbeing and maximizes energy production. = Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression. = Immobility promotes constipation. = To prevent stiffness of the muscles such as foot drop and deconditioning of the clients muscles.

Evaluation After 24 hours of nursing intervention the nurse is able to assess the ROM of the patient and be able to teach the active and passive, and other therapeutic exercises that can be done for the patient to prevent stiffness of the muscles such as foot drop and deconditioning of the clients muscles. After 8 hours of nursing intervention the nurse has assessed the kind of activities that the patient can do and those activities she can not.

4. Encourage adequate intake of fluids/nutritious foods. 5. Assess patient or caregivers knowledge of immobility and its implications.

6. Assess elimination status (e.g., usual pattern, present patterns, signs of constipation). 7. Teach to the relatives the passive and active exercises and other therapeutic exercises for the patient.

Dependent: 1. Administration of medications.

= Nurses are not allowed to administer medications unless ordered by the physician. = To develop individual exercise/mobility program and identify appropriate mobility devices

Collaborative: 1. Consult with physical/occupational therapist.