IMPAIRED PHYSICAL MOBILITY Nursing Care Plan

This is a nursing care plan sample about impaired physical mobility of Mr. Tulfido, 40 years old, happy-go-lucky, who loves to play tennis, live streaming while playing console games, and barbecue party almost every night. Mr. Tulfido retired early at the age of 35. He is a former police officer who had very great achievements that even his chief did not want him to retire. Unfortunately, one day, Mr. Tulfido experienced dizziness, felt down and began unconscious. When he wakes up, he can't control his right-side of his body and he is unable to talk clearly.

 

Assessment:

Subjective:

"I cannot move half of my body, it was dead." verbalized by the patient.

Objective:

- Trouble speaking

- Difficulty to understand what others are saying

- Right-half of the body was paralysis

- Muscle weakness

- Numbness of the right face, right arms and right leg

- Drooling of saliva on the right side of the mouth when trying to speak

- Having trouble in walking

 

Diagnosis:

Impaired physical mobility related to partial paralysis as evidenced by numbness of the right face, right arms and right leg, and having trouble in walking.

 

You can also consider using diagnoses of Self-Care Deficit and Risk for Injury for limitation of movement is the etiology. Remember, if the patient is completely immobile, do not use this diagnosis instead use Risk for Disuse Syndrome. If the client can exercise but does not, you can use diagnosis Sedentary Lifestyle. If the client has no limitations in movement but is deconditioned and has reduced endurance, you can use diagnosis Activity Intolerance.

 

Planning:

After 8 hours of nursing intervention, the patient will report increased strength and endurance of limbs by demonstrating the use of adaptive devices to increase mobility, able to use safety measures to minimize potential for injury, able to demonstrate measures to increase mobility, and able to evaluate pain and quality of management.

 

Interventions:

- Consult with physical therapy for evaluation and development of a mobility plan for Mr. Tulfido who is a patient that is unable to move his right-side of the body. Evaluate level of motivation and depression of Mr. Tulfido. Refer to a specialist as needed. Encourage the patient to perform exercise regimens for his specific joints as prescribed by the doctor, nurse practitioner, or a physical therapist.

 

- Promote optimal mobility and movement by explaining the problem to Mr. Tulfido and the objective of each exercise for his mobility plan. Establish short-term goals and ensure that initial his exercises are easy and require minimal strength and coordination. Progress only if the patient is successful at his present exercise. Provide written instructions for prescribed exercises after demonstrating and observing return demonstration. Document and discuss Mr. Tulfido's improvement specifically like when there's improvement in lifting his legs, you can write "Mr. Tulfido can now lift leg 2 inches higher." Increase his limb mobility and determine the type of range of motion appropriate for him. Note if its passive ROM, active assistive ROM, active ROM, or active resistive ROM. Perform passive or active resistive ROM exercise where the frequency determined by patient's condition. Perform passive ROM on his affected right limbs. Teach Mr. Tulfido to perform active ROM exercises on unaffected limbs at least four times a day; if possible, this would prevent muscle loss on his unaffected side. Let Mr. Tulfido to do exercise slowly to allow his muscles time to relax, and support his extremity above and below the joint to prevent strain on his joints and tissues. For passive ROM, the supine position is most effective. The patient who performs ROM himself can use a supine or a sitting position. Perform the ROM daily with bed bath three to four times daily if there are specific problem areas. Try to incorporate activities of daily living. Support his extremity with pillows to prevent or reduce swelling.

 

- In positioning the patient, put Mr. Tulfido in proper alignment to prevent complications. Use a footboard and avoid the patient to prolonged sitting or lying in the same position. Change the position of his shoulder joints every 2 to 4 hours. Use a small pillow or no pillow when Mr. Tulfido is in Fowler's position. Support his hand and wrist in natural alignment. If Mr. Tulfido is in supine or prone, place a rolled towel or small pillow under his lumbar curvature or under the end of the rib cage. Place a trochanter roll alongside the hips and upper thighs. If the client is supine or prone, place a rolled towel or small pillow under the lumbar curvature or under the end of his rib cage. Place a trochanter roll alongside of his hips and his upper thighs. If the patient is in the lateral position, place pillow(s) to support his leg from groin to foot, and use a pillow to flex his shoulder and elbow slightly. If needed, support the lower foot in dorsal flexion with a towel roll or special boot. Arms abducted from the body with pillows and elbows in slight flexion. Wrist in a neutral position, with fingers slightly flexed and thumb abducted and slightly flexed.

 

- Medicate for pain as needed, especially before any Mr. Tulfido's activity. Apply heat or cold compress to reduce pain, inflammation, and hematoma.

 

Evaluation:

After 8 hours of nursing intervention, the patient reported increased strength and endurance of limbs by demonstrating the use of adaptive devices to increase mobility, was able to use safety measures to minimize potential for injury, was able to demonstrate measures to increase mobility, and was able to evaluate pain and quality of management.

 

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