Nursing diagnosis: impaired physical Mobility related to skeletal deformity; pain, discomfort; intolerance to activity, decreased muscle strength
Possibly evidenced by
Reluctance to attempt movement and inability to purposefully move within the physical environment
Limited ROM; impaired coordination; decreased muscle strength, control and mass (late stages)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain position of function with absence or limitation of contractures.
Maintain or increase strength and function of affected and/or compensatory body part.
Demonstrate techniques and behaviors that enable resumption or continuation of activities.
Nursing intervention with rationale:
1. Evaluate and then continuously monitor degree of joint inflammation and pain.
Rationale: Level of activity and exercise depends on progression or resolution of inflammatory process.
2. Maintain bedrest or chair rest when indicated. Schedule activities providing frequent rest periods and uninterrupted nighttime sleep.
Rationale: Person with RA needs a good balance between rest and exercise, with more rest when disease is active and more exercise when it is not. Systemic rest is mandatory during acute exacerbations and important throughout all phases of disease to reduce fatigue and improve strength.
3. Assist with active, or perform passive, ROM and resistive exercises and isometrics when able.
Rationale: Maintains and may improve joint function, muscle strength, and general stamina. Note: Inadequate exercise leads to joint stiffening, whereas excessive activity can damage joints.
4. Encourage client to maintain upright and erect posture when sitting, standing, and walking.
Rationale: Maximizes joint function and maintains mobility.
5. Discuss and provide safety needs, such as raised chairs and toilet seat, use of handrails in tub or shower and toilet, proper use of mobility aids or wheelchair safety.
Rationale: Helps prevent accidental injuries and falls.
6. Reposition frequently using adequate personnel. Demonstrate and assist with transfer techniques and use of mobility aids, such as walker, cane, or trapeze.
Rationale: Relieves pressure on tissues and promotes circulation. Facilitates self-care and client’s independence. Proper transfer techniques prevent shearing abrasions of skin.
7. Position with pillows, sandbags, or trochanter roll. Provide joint support with splints.
Rationale: Promotes joint stability, reducing risk of injury, and maintains proper joint position and body alignment, minimizing contractures.
8. Suggest using small or thin pillow under neck.
Rationale: Prevents flexion of neck.
9. Provide foam or alternating pressure mattress.
Rationale: Decreases pressure on fragile tissues to reduce risks of immobility and development of decubitus ulcers.
10. Determine appropriateness of, and ability to use, scooter or special enhancements to automobile such as hand controls and wide mirrors.
Rationale: Facilitates movement within the environment, decreases fatigue, and promotes independence.