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Impaired Physical Mobility

This nursing document outlines the care plan for a patient who suffered a CVA and has resulting impaired physical mobility and right hemiplegia. The plan includes establishing rapport, monitoring vitals, assisting with mobility and exercises, safety measures, energy conservation techniques, passive range of motion, and involving family. The goals are to increase strength and function of affected areas, maintain optimal positioning, and enable resumption of activities and skin integrity while participating in ADLs. Evaluation includes subjective experience and objective measurements of limited range of motion, strength differences, and mobility changes.

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Charmaine Chua
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696 views3 pages

Impaired Physical Mobility

This nursing document outlines the care plan for a patient who suffered a CVA and has resulting impaired physical mobility and right hemiplegia. The plan includes establishing rapport, monitoring vitals, assisting with mobility and exercises, safety measures, energy conservation techniques, passive range of motion, and involving family. The goals are to increase strength and function of affected areas, maintain optimal positioning, and enable resumption of activities and skin integrity while participating in ADLs. Evaluation includes subjective experience and objective measurements of limited range of motion, strength differences, and mobility changes.

Uploaded by

Charmaine Chua
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CUES

NURSING DIAGNOSIS Impaired physical mobility r/t neuromuscular involvement secondary to CVA

NURSING OBJECTIVES General:

NURSING INTERVENTIONS > Establish rapport. >Monitor V/S. >Note emotional/ behavioral responses to problems of immobility. >Determine readiness to engage in activities/ exercises. >Assist patient resposition self on a regular schedule. >Provide for safety measures including fall prevention. >Identify energy conserving techniques for ADLs. >Involve patient significant others in care assisting them to learn ways of managing problems of immobility. >Assist patient to do passive ROM. >Support affected body parts/joints using pillows. >Provide restful environment for patients after periods of exercise.

RATIONALE

EVALUATION

Subjective:

Objective: >right hemiplegia >limited ROM >difficulty turning >slowed movement >muscle strength of R arm: 0/5 R leg: 0/5 L arm: 5/5 L leg: 5/5 >gait changes >postural instability during performance of routine ADLs >movement induced shortness of breath/tremors

Specific:

>Increase strength and function of affected or compensatory body part. >Maintain optimal position of function >Demonstrate techniques or behaviors that enable resumption of activities >Maintain skin integrity >Participate in ADLs and desired activities.

> To promote cooperation. >To have baseline data. >To assess functional ability. Feelings of frustration or powerlessness may impede attainment of goals. >To assess expected level of participation. >To promote optimal level of function and prevent complications. >To prevent occurrence of injury. >Limits fatigue, maximizing participation. >To promote wellness.

>To promote wellness. >To maintain position of function and reduce risk of pressure ulcers. >To reduce fatigue; to promote circulation and prevent contracture.

>Change positions at least 2 hr (supine, side lying) and possibly more if placed on affected side.

>Observe affected side for color, edema, or other signs of compromised circulation. >Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary.

>Reduces risk of tissue ischemia/ injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/ decubitus ulcer. >Edematous tissue is more easily traumatized and heals more slowly. >Pressure points over bony prominences are most at risk for decreased perfusion/ ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus ulcer development. >To prevent development of pressure ulcers. >Promotes well-being and maximizes energy production.

>Provide regular skin care to include pressure area management. >Encourage adequate intake of fluids/ nutritious foods.

Collaborative: >Consult with physical/ occupational therapist/ mobility program and >To develop individual exercise/ mobility program and identify appropriate mobility devices.

identify appropriate mobility devices. >Review individual dietary needs. >To identify appropriate vitamin/ herbal supplements.

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