Nursing diagnosis: impaired physical mobility related to pain and discomfort, muscle spasms, restrictive therapies, such as bedrest, traction, neuromuscular impairment
Possibly evidenced by
Reports of pain on movement
Reluctance to attempt or difficulty with purposeful movement
Impaired coordination, limited ROM, decreased muscle strength
Desired Outcomes/Evaluation Criteria—Client Will
Immobility Consequences: Physiological
Verbalize understanding of situation, risk factors, and individual treatment regimen.
Be free of complications.
Demonstrate techniques and behaviors that enable resumption of activities.
Maintain or increase strength and function of affected or compensatory body part.
Nursing intervention with rationale
1. Perform passive ROM exercises and assist with active exercises.
Rationale: ROM exercises and good body mechanics strengthen abdominal muscles and flexors of spine.
2. Encourage lower leg and ankle exercises. Evaluate for edema, erythema of lower extremities, and calf pain or tenderness.
Rationale: These exercises stimulate venous return, decrease venous stasis, and reduce risk of thrombus formation.
3. Provide good skin care. Gently massage pressure points after each position change. Check skin under brace periodically.
Rationale: Gentle massage and frequent repositioning reduce the risk of skin irritation and breakdown. Frequent skin assessments and prompt interventions afford early detection of skin breakdown.
4. Encourage diet high in fiber and adequate fluid intake.
Rationale: Reduces risk of constipation related to decreased level of activity.
5. Note emotional and behavioral responses to immobility. Provide diversional activities.
Rationale: Forced immobility may heighten restlessness and irritability. Diversional activity aids in refocusing attention and enhances coping with actual and perceived limitations.
6. Provide for safety measures, as indicated by individual situation.
Rationale: Depending on area of involvement or type of procedure, imprudent activity increases chance of spinal injury.
7. Assist with activity, progressive ambulation, and therapeutic exercises.
Rationale: Activity depends on individual situation. It should begin as early as possible and usually progresses slowly, based on client tolerance.
8. Demonstrate use of adjunctive devices, such as walker or cane.
Rationale: Appropriate use of adjunctive devices provides stability and support by compensating for altered muscle tone, strength, balance, and gait.
9. Administer pain medication on a regular schedule, or approximately 30 minutes before anticipated painful procedures or activities as indicated.
Rationale: Client’s anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort, and improve motivation to increase activity.
10. Apply antiembolism stockings as indicated.
Rationale: Promotes venous return, reducing risk of deep vein thrombosis (DVT).