NURSING CARE PLANIdentified Problem: Impaired bed mobility

Nursing Diagnosis: Impaired bed mobility r/t pain at surgical site and fear of causing hernia to rupture

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATIONSubjective:

‘’ dili paku kalakaw kay sa opera nga samad’’ as verbalized by the patient.

Objective:

- Unable to move from sitting to lying position

- Unable to ambulate self- Independent physical

movement of the body.

Short term objectives:

Within three days of providing appropriate nursing care patient would able to verbalize feeling of increased strength and ability to move and demonstrate use of adaptive equipment.

Long term objectives:

After three days of providing appropriate nursing care patient would able mutually defined goals of increased ambulation and exercise that include individual choice, preference and enjoyment in th exercise prescription.

1. Assess the client for cause of impaired mobility. Determine whether cause is physical, psychological, or motivational.

2. Monitor and record the client’s ability to tolerate activity.

3. Observe for and if possible, treat pain with massage, heat pack to affected area, or medication. Ensure that the client is not over sedated.

4. Consult with the physical therapist for further evaluation, strength training and development of mobility plan.

5. Obtain assistive devices needed for activity such as weighted vest, walker, crane, crutches.

6. Perform passive ROM exercises at least twice a day unless contraindicated; repeat each maneuver three times.

7. Help the client achieve mobility and start walking as soon as possible if not contraindicated.

8. Increase independence in ADLs, encouraging self-efficacy and discouraging helplessness as the client gets stronger.

1. Some clients choose not to move because of psychological factors such as fear of falling or pain.

2. Use valid and reliable screening procedures and tools to assess the client’s preparation in exercise health screening and risk stratification for exercise testing.

3. Pain limits mobility and is often exacerbated by movement.

4. Prescribing a regimen of regular physical activity hat includes both aerobic exercise and muscle strengthening activities is beneficial to minimizing impaired physical mobility.

5. Assistive devices can help mobility.

6. Physical rehabilitation interventions were found to be safe, reduced disability and resulted in few adverse events.

7. Early mobilization of clients generally prevents complications such as deep vein thrombosis.

8. Providing unnecessary assistance with transfers and bathing activities may promote dependence and loss mobility.

Short term:

After providing nursing intervention for three days patient was able to have confidence in moving his self and ambulating.

Long term:

After rendering nursing care patient is able to patient was able to ambulate his self from time to time and independently able to stand without fear of falling.