Ncp Case Pres

Assessment Subjective: “Kita niyo naman, di na siya makagalaw...” As verbalized by client’s wife

Diagnosis Immobility related to prolonged bed rest and limited strength secondary to present illness. Rationale:

Objective: Inability to move purposefully within the physical environment, including bed motility, transfers and ambulation

Limitation in independent, purposeful physical movement of the body or of one or more extremities

Decreased muscle endurance, strength, control or mass

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility

Functional level class: 4 (dependent, does not participate in activity, requires help from another person and equipment or device

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and

Limited ROM

Planning

Intervention

Short term goal: Independent: > after 2 hrs of nursing intervention The * Assess for patient: impediments to mobility Performs physical activity with * Assess patient or assistance caregiver’s knowledge of immobility and its implications. Long Term goal : > after 1 week of nursing intervention patient will remain * Assess skin integrity. free of complications Check for signs of of immobility as redness, tissue ischemia evidenced by intact (especially over ears, skin, absence of shoulders, elbows, thrombophlebitis and sacrum, hips, heels, normal bowel pattern. ankles, and toes).

Rationale

*Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression. *Pressure sores develop more quickly in patients with a nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise

*Pressure sores develop * Monitor input and more quickly in patients output record and with a nutritional deficit. nutritional pattern. Proper nutrition also Assess nutritional needs provides needed energy as they relate to for participating in an immobility (e.g., exercise possible hypocalcemia, negative nitrogen *Immobility promotes balance). constipation.

Evaluation After nursing intervention, Goal was met. after 2 hrs of nursing intervention The patient Performed physical activity with assistance and assistive devices devices

Long term goal: After 1 week of nursing intervention patient remained free of complications of immobility as evidenced by intact skin, absence of thrombophlebitis and normal bowel pattern

ie: wheelchair Age: 74 years old BP:

less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility.

* Assess elimination status (e.g., usual pattern, present patterns, and signs of constipation). Evaluate need for assistive devices. Proper use of wheelchairs, canes, transfer bars, and other assistance can promote activity and reduce danger of falls.

*The longer the patient remains immobile the greater the level of debilitation that will occur.

* Evaluate the safety of the immediate environment. Obstacles such as throw rugs, children’s toys, and pets *Mobility aids can can further impede increase level of one’s ability to mobility. ambulate safely. * Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation.

*This promotes a safe environment. *This optimizes circulation to all tissues and relieves pressure.

* Facilitate transfer training by using appropriate assistance of persons or devices when transferring patients to bed, chair, or stretcher.

*This prevents footdrop and/or excessive plantar flexion or tightness. Support feet in dorsiflexed position.

*Decreased chest excursions and stasis of * Keep side rails up and secretions are associated bed in low position. with immobility. * Turn and position every 2 hours or as needed. * Maintain limbs in functional alignment (e.g., with pillows, sandbags, wedges, or prefabricated splints). * Perform passive or active assistive ROM exercises to all extremities. Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength and endurance. * Turn patient to prone or semiprone position

*Liquids optimize hydration status and prevent hardening of stool.

once daily unless contraindicated. This drains bronchial tree. Clean, dry, and moisturize skin as needed. * Encourage coughing and deep-breathing exercises. These prevent buildup of secretions. * Encourage liquid intake of 2000 to 3000 ml/day unless contraindicated. . * Set up a bowel program (e.g., adequate fluid, foods high in bulk, physical activity) as needed. Record bowel activity level. * Instruct patient or caregivers regarding hazards of immobility. Emphasize importance of measures such as position change, ROM, coughing, and

*To promote safety

*This increases lung expansion. *Antispasmodic medications may reduce muscle spasms or spasticity that interferes with mobility.

exercises. * Instruct patient/family regarding need to make home environment safe. A safe environment is a prerequisite to improved mobility. Dependent: * Use incentive spirometer as indicated. * Administer medications as appropriate. (i.e. Antispasmodic medications)