Impaired Physical Mobility - Nursing Care Plan

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Impaired Physical Mobility - Nursing Care Plan

Nursing Diagnosis for Impaired Physical Mobility

Musculoskeletal System:

1. Risk for Injury (fall when ambulation)
related to:

• limited endurance.
• a decrease in muscle strength.
• stiffness and joint pain.
• orthostatic hypotension.

2. Impaired Physical Mobility (individuals have limitations on the ability to physically move independently)
related to:

• decreased range of motion.
• bed rest.
• a decrease in muscle strength.
• pain or discomfort.

characteristics:

• Not able to move in bed and the environment, not able to move or ambulation.
• Limitations on the movement of the joints.
• Decreased muscle strength and control of the movement of which is restricted.

Cardiovascular System

1. Activity Intolerance
related to:

• long-term bedrest,
• general weakness,
• imbalance between demand and supply of oxygen.

2. Ineffective Tissue perfusion
related to:

• disorders of blood flow through the vein.
• edema.

Respiratory System

1. Ineffective breathing pattern
related to:

• decrease in lung expansion.
• chest muscle atrophy.
• administration of depressant agents (analgesics, sedatives).

2. Impaired gas exchange
related to:

• Ineffective breathing pattern.
• decline in lung development.
• buildup of lung secretions.

3. Ineffective airway clearance
related to:

• stasis of pulmonary secretions.
• imprecision body position.

Metabolic and Nutritional Systems

1. Imbalanced Nutrition Less Than Body Requirements
related to:

• intake is inadequate.
• catabolism of muscle mass.

2. Imbalanced Nutrition More than Body Requirements
related to:

• imbalance between intake with energy expenditure.

Urinary System

1. Risk for infection: urinary
related to:

• stasis of urine,
• obstruction of urine flow.

 Elimination System

1. Constipation
related to:

• decrease in physical activity,
• lack of privacy is maintained,
• inadequate diet.

Integumentary System

1. Impaired skin integrity
relate to:

• Limitations mobilization.
• Skin surface pressure.
• Frictional forces on the surface of the skin ..

Planning

Musculoskeletal system :

• Muskuloskeltal maintain normal function.
• Normal ROM in all joints.
• Normal strength and muscle mass.
• Actively participate in the activities.

Intervention:

• Create a workout schedule ROM: active, passive and isotonic.
• Encourage active participation remedy selfcare activities.
• Bodyaligment good position.
• Ambulation aids clients if they can or standing on the side of the bed.

Cardiovascular system

• Minimal cardiovascular disorders, characterized by: a standard backflow; adequate vein (no edema, pain, inflammation, venous distention, skin perubahn)

Intervention:

• Monitor vital signs.
• Teach clients how and when should Valsalva maneuver.
• Wear tights if possible.
• Elevate the legs about 20 minutes every day.
• Assess skin in depressed areas.
• View and add also the musculoskeletal system interventions.

Respiratory system

• Maintain normal respiratory function, characterized by clean breath sounds during auscultation, normal chest expansion, no chest pain, fever, chest muscle movement embolism and atelectasis.

Intervention:

• Assess breath sounds and chest expansion every 8 hours.
• Teach clients effective deep breathing and coughing.
• Change the position every 2 hours, and ambulation if possible and place it on a chair.
• Diagfragma abdominal breathing exercises.

Elimination System

• Normal elimination pattern marked no less urine output 1500 ml, urine specific gravity from 1 to 1.025 acidic urine. There is no sign of retention / urinary infection.
• Shaped and soft stool, bowel movement over 2-3 days.

Intervention:

• Monitor the color, density, total acidity of urine, feces color and characteristics, frequency of defecation.
• Diet: increase in protein, calories, fiber.
• Vitamin and mineral supplements.
• Parenteral and enteral supplements.
• Early ambulation and ROM exercises.

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