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.
For more samples of nursing
care plan you are free to check it out in our NCP LIST page.
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