Possibly evidenced by
Inability to purposefully move within the physical environment, impaired coordination, limited range of motion (ROM), decreased muscle strength and control
Desired Outcomes/Evaluation Criteria—Client Will
Immobility Consequences: Physiologic
Maintain or increase strength and function of affected or compensatory body part.
Maintain optimal position of function as evidenced by absence of contractures and footdrop.
Demonstrate techniques and behaviors that enable resumption of activities.
Maintain skin integrity.
Nursing intervention with rationale
1. Assess functional ability and extent of impairment initially and on a regular basis. Classify according to a 0 to 4 scale.
Rationale: Identifies strengths and deficiencies and may provide information regarding recovery. Assists in choice of interventions because different techniques are used for flaccid and spastic types of paralysis.
2. Change positions at least every 2 hours (supine, side lying) and possibly more often if placed on affected side.
Rationale: Reduces risk of tissue ischemia and injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown and pressure ulcers.
3.Position in prone position once or twice a day if client can tolerate.
Rationale: Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe.
4. Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.
Rationale: Prevents contractures and footdrop and facilitates use when or if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.
5. Use arm sling when client is in upright position, as indicated.
Rationale: During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome.
6. Observe affected side for color, edema, or other signs of compromised circulation.
Rationale: Edematous tissue is more easily traumatized and heals more slowly.
7. Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads, as necessary.
Rationale: Pressure points over bony prominences are most at risk for decreased perfusion and ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus ulcer development.
8. Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises, such as quadriceps or gluteal exercise, squeezing rubber ball, and extension of fingers and legs and feet.
Rationale: Minimizes muscle atrophy, promotes circulation, and helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive and imprudent stimulation can predispose to recurrence of bleeding.
9. Assist client to develop sitting balance (such as raise head of bed; assist to sit on edge of bed, having client use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance— put flat walking shoes on client, support client’s lower back with hands while positioning own knees outside client’s knees, and assist in using parallel bars and walker.
Rationale: Aids in retraining neuronal pathways, enhancing proprioception and motor response.
10. Get client up in chair as soon as vital signs are stable except following cerebral hemorrhage.
Rationale: Helps stabilize BP, restoring vasomotor tone, and promotes maintenance of extremities in a functional position and emptying of bladder and kidneys, reducing risk of urinary
stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleeding and infarction.