Daisy
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- Words: 260
- Pages: 2
Cues
Nursing Diagnosis
Inference
Planning
Nursing Intervention
Rationale
Evaluation
S> “Nahihirapan akong maglakad as verbalized by the patient”
Impaired Physical Mobility Immobility r/t Limited strength
Mobility is also related to body changes from aging. 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 Limited strength
After 8 hrs of nursing intervention Patient will independently ambulate five feet with assistive device by discharge..
1.Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation
1.The longer the patient remains immobile the greater the level of debilitation that will occur
2. Allow patient to perform tasks at his or her own rate. Do not rush patient.
2. Encourage independent activity as able and safe.
After 8 hrs of nursing intervention Patient will independently ambulate five feet with assistive device by discharge as evidence by imposed, patient's reluctant to move.
O> Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation * Reluctance to attempt movement * Limited range of motion (ROM), coordination * Inability to perform action as instructed
3. This 3. Keep side promotes a rails up and bed safe in low position. environment. 4. Maintain limbs in functional
4. This prevents footdrop and/or
alignment (e.g., with pillows, sandbags, wedges, or prefabricated splints).
excessive plantar flexion or tightness.
5. Perform passive or active assistive ROM exercises to all extremities.
5. Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength and endurance.
Nursing Diagnosis
Inference
Planning
Nursing Intervention
Rationale
Evaluation
S> “Nahihirapan akong maglakad as verbalized by the patient”
Impaired Physical Mobility Immobility r/t Limited strength
Mobility is also related to body changes from aging. 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 Limited strength
After 8 hrs of nursing intervention Patient will independently ambulate five feet with assistive device by discharge..
1.Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation
1.The longer the patient remains immobile the greater the level of debilitation that will occur
2. Allow patient to perform tasks at his or her own rate. Do not rush patient.
2. Encourage independent activity as able and safe.
After 8 hrs of nursing intervention Patient will independently ambulate five feet with assistive device by discharge as evidence by imposed, patient's reluctant to move.
O> Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation * Reluctance to attempt movement * Limited range of motion (ROM), coordination * Inability to perform action as instructed
3. This 3. Keep side promotes a rails up and bed safe in low position. environment. 4. Maintain limbs in functional
4. This prevents footdrop and/or
alignment (e.g., with pillows, sandbags, wedges, or prefabricated splints).
excessive plantar flexion or tightness.
5. Perform passive or active assistive ROM exercises to all extremities.
5. Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength and endurance.
