Nursing diagnosis: impaired physical Mobility related to neuromuscular skeletal impairment, pain or discomfort, restrictive therapies—limb immobilization, psychological immobility
Possibly evidenced by
Inability to move purposefully within the physical environment, imposed restrictions
Reluctance to attempt movement, limited ROM
Decreased muscle strength or control
Desired Outcomes/Evaluation Criteria—Client Will
Regain and maintain mobility at the highest possible level.
Maintain position of function.
Increase strength and function of affected and compensatory body parts.
Demonstrate techniques that enable resumption of activities, especially activities of daily living (ADLs).
Nursing intervention with rationale:
1. Assess degree of immobility produced by injury and/or treatment and note client’s perception of immobility.
Rationale: Client may be restricted by self-view or self-perception out of proportion with actual physical limitations, requiring information and interventions to promote progress toward wellness.
2. Encourage participation in diversional or recreational activities. Maintain stimulating environment—radio, TV, newspapers, personal possessions, pictures, clock, calendar, and visits from family and friends.
Rationale: Provides opportunity for release of energy, refocuses attention, enhances client’s sense of self-control and self-worth, and aids in reducing social isolation.
3. Instruct client in active, or assist with passive, ROM exercises of affected and unaffected extremities.
Rationale: Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse.
4. Encourage use of isometric exercises, starting with the unaffected limb.
Rationale: Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding or edema is present.
5. Provide footboard, wrist splints, and trochanter or hand rolls, as appropriate.
Rationale: Useful in maintaining functional position of extremities, hands or feet, and preventing complications such as contractures or footdrop.
6. Place in supine position periodically if possible when traction is used to stabilize lower limb fractures.
Rationale: Reduces risk of flexion contracture of hip.
7. Instruct in, and encourage use of, trapeze and “post position” for lower limb fractures.
Rationale: Facilitates movement during hygiene, skin care, and linen changes; reduces discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed.
8. Assist with and encourage self-care activities such as bathing, shaving, and oral hygiene.
Rationale: Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness.
9. Assist with mobility by means of wheelchair, walker, crutches, and/or canes as soon as possible. Instruct in safe use of mobility aids.
Rationale: Early mobility reduces complications of bedrest, such as phlebitis, and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and client safety.
10. Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement.
Rationale: In the presence of musculoskeletal injuries, early good feeding is needed as nutrients required for healing are rapidly depleted. This can have a profound effect on muscle mass, tone, and strength. Note: Protein foods increase contents in small bowel, resulting in gas formation and constipation. Therefore, gastrointestinal (GI) function should be fully restored before protein foods are increased.