Nursing Care Plan


Return to Care Plan Listing
 






Medical Diagnoses: Impaired Physical Mobility; Cognitive impairment, Pain, loss of integrity of bone structures

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Patient confused and not able to provide subjective data regarding current health condition.

     

     

     

     

     

Objective

Recent ampuation of right 5th toe. Bed rest per doctor orders. BIL feet bandaged and receive wound care.  Pain 7/10.



Problem

    

Impaired Physical Mobility

    

    

    

    

    

Long Term:

Client will meet mutually defined goals of ambulation at the time of discharge.

Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitating clients (Tempkin, Tempkin & Goodman, 1997).

If the client is immobile, consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin with the following exercises:

Active ROM exercises using both upper and lower extremities (e.g., flexing and extending at ankles, knees, hips)

Chin-ups and pull-ups using a trapeze in bed (may be contraindicated in clients with cardiac conditions)

Strengthening exercises such as gluteal or quadriceps sitting exercises

These exercises help reverse weakening and atrophy of muscles (Kasper et al, 2005).

*

    

    

    

    

Client was able to meet the goals of ambulation per doctor’s orders. Goal is met will continue to monitor until discharge.



According to chart, pt was already consulted and will continue to work with patient on a daily basis until discharge.

According to the chart, client should be on bedrest but able to perform active ROM, performed active ROM in all four extremities and it was tolerated well by client.

R/T

Cognitive impairment,

Pain,

loss of integrity of bone structures

prescribed movement restrictions

    

Short Term:

Client will increase physical activity by end of shift on [date] at 1300.



Monitor and record the client's ability to tolerate activity and use all four extremities; note pulse rate, blood pressure, dyspnea, and skin color before and after activity. If the client is immobile, perform passive range of motion (ROM) exercises at least twice a day unless contraindicated; repeat each maneuver three times. Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. The formation of contractures starts after 8 hours of immobility (Fletcher, 2005).

    

*

Client was able to increase physical actvity by performing active ROM by 1300. Goal met.



Performed active ROM once during shift and told nurse to follow up with another session of ROM exercised. Watched for changes in normal blood pressure and obesevered for dyspnea and skin color befor and after ROM exercises.

AEB

Bandaged feet, pain 7/10, and doctors prescribed orders.

    

    

    

    

    

    

 

1,600 Respiratory review flash cards, download now and ace your exams

  

References:

     

Fletcher K: Immobility: geriatric self-learning module, Medsurg Nurs 14(1):3537, 2005.

     

Kasper DL et al, editors: Harrison's principles of internal medicine, ed 16, New York, 2005, McGraw-Hill.

     

Tempkin T, Tempkin A, Goodman H: Geriatric rehabilitation, Nurs Pract Forum 8(2):5963, 1997.



Return to Table of Contents