Cues Subjective: Ang hirap ng may ganito (traction).

Bawal kumilos, hindi man lang ako makapunta sa banyo para maligo. Hinihintay ko pa na may bisita ako para lang makapaglinis ng sarili ko verbalized by the client. Objective: Client is on modified bucks extension traction. Client is on semifowlers position. Client had fracture on the proximal 3rd of his left femur due to gunshot. Client had three gunshots on his abdomen with mainly his duodenum and jejunum as well as in his right leg. Provisional Diagnosis: Hypovolemic shock 2 to multiple GSW Measurement: Red Blood Cells

Nursing Diagnosis Impaired Physical Mobility related to musculoskeletal impairment possibly evidenced by inability to move purposefully within the physical environment, imposed restriction.

Analysis Impaired Physical Mobility Limitation in independent, purposeful physical movement of the body or of one or more extremities. (Nurses Pocket Guide-Diagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr p.457) Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation

Planning Goals: After 8 hours of nursing intervention, the client will be able to verbalize understanding of situation and individual treatment regimen and safety measures independently. Objectives: After 1 hour of nursing intervention, the client will be able to: 1. To identify at least five out of eight causative/contributing factors

Intervention

Rationale

Evaluation The goal was met.

Determine diagnosis that contributes to immobility

These conditions can cause physiological and psychological problems that can seriously impact physical, social, and economic well-being. Identifies potential impairments and determines type of interventions needed to provide for clients safety To determine presence of characteristics of clients unique impairment and to guide choice of interventions Identified mobility as the most important functional ability that determines the degree of independence and healthcare needs among older persons.2 While aging per se does not cause impaired mobility, several

Met. The client was able to identify five out of eight causative/contributing factors.

Note factors affecting current situation and potential time involved.

Assess clients developmental level, motor skills, ease and capability of movement, posture and gait. Note older clients general health status

3.77 x 10^12/L Normal Findings: (Males) 5.5-6.5 x10^12/L Hemoglobin 11.80 g/dL Normal Findings: (Males) 14-16 g/dL Hematocrit 0.33 L/L Normal Findings: (Males) 0.42-0.52 L/L Lymphocytes 0.21 Normal Findings: 0.25-0.35 Eosinophils 0.01 Normal Findings 0.03-0.05

facilities or sent home for physical therapy in the home environment. Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment. (Nursing Care Plans: Nursing Diagnosis and Intervention by Gulanick, Myers,

predisposing factors in addition to age-related changes can lead to immobility Evaluate for presence/degree of pain, listening to clients description about manner in which pain limits mobility. Ascertain clients perception of activity/exercise needs and impact of current situation. Identify cultural beliefs and expectations affecting recovery/response to long-term limitations. Assess nutritional status and clients report of energy level. To determine needed interventions for pain management

Helps to determine clients expectations/beliefs related to activity and potential long-term effect of current immobility. Also identifies barriers that may be addressed

Deficiencies in nutrients and water, electrolytes and minerals can negatively affect energy and activity tolerance. Client may be restricting activity because of weakness/debilitation, actual injury during a fall, or from psychological distress that can persist after a fall. Identifies strengths and deficits impaired physical mobility and may provide information regarding potential for recovery Impairments related to age, chronic or acute disease condition, trauma, Met. The client was able to report three out of five of his functional ability.

Determine history of falls and relatedness to current situation.

2. To report three out of five of his functional ability

Determine degree of immobility in relation to 04 scale, noting muscle strength and tone, joint mobility, cardiovascular status, balance, and endurance. Determine degree of perceptual/cognitive impairment and ability to follow directions

Klop, Galanes, Gradishar and Puzas) Observe movement when client is unaware of observation Note emotional/behavioral responses to problems of immobility

surgery, or medications require alternative interventions or changes in plan of care. To note any incongruence with reports of abilities. Can negatively affect selfconcept and self-esteem, autonomy, and independence. Feelings of frustration and powerlessness may impede attainment of goals. Social, occupational, and relationship roles can change, leading to isolation, depression, and economic consequences Studies have shown that as much as 5.5% of muscle strength can be lost each day of rest and immobility.5 Other complications include changes in circulation and impairments of organ function affecting the whole person To maximize potential for mobility and optimal function. May be necessary when client is using avoidance or controlling behavior, or is not aware of own abilities due to anxiety/fear. To enhance circulation to Met. The client was able to explain at least five of the optimal level of function and measures on how to prevent complications.

Determine presence of complications related to immobility

3. To explain at least five of the optimal level of function and measures on how to prevent complications.

Assist with treatment of underlying condition(s) Discuss discrepancies in movement with client aware and unaware of observation and methods for dealing with identified problems. Assist/have client reposition self

on a regular schedule as dictated by individual situation Review/encourage use of proper body mechanics Demonstrate/assist with use of side rails, overhead trapeze, roller pads, hydraulic lifts/chairs Support affected body parts/joints using pillows/rolls, foot supports/shoes, gel pads, etc., Provide/recommend egg-crate, alternating air-pressure, or water mattress. Use padding and positioning devices

tissues, reduce risk of tissue ischemia. To prevent injury to client and caregiver For position changes/transfers. Instruct in safe use of walker/cane for ambulation. To maintain position of function and reduce risk of pressure ulcers. Reduces tissue pressure and aids in maximizing cellular perfusion to prevent dermal injury. To prevent stress on tissues and reduce potential for disuse complications. Reduces sensory deprivation, enhances selfconcept and sense of independence, and improves body strength and function. To reduce fatigue.

Encourage clients participation in self-care activities, physical/occupational therapies as well as diversional/recreational activities. Provide client with ample time to perform mobility-related tasks. Schedule activities with adequate rest periods during the day Avoid routinely assisting or doing for client those activities that client can do for self. Identify/encourage energyconserving techniques for

Caregivers can contribute to impaired mobility by being overprotective or helping too much. Limits fatigue, maximizing

ADLs. Note change in strength to do more or less self-care

participation. To promote psychological and physical benefits of self-care and to adjust level of assistance as indicated. To permit maximal effort/involvement in activity. To reduce pressure on sensitive areas and to prevent development of problems with skin integrity. Promotes well-being and maximizes energy production. Enhances commitment to plan, optimizing outcomes. Multiple options provide client choices and variety May need instruction and to give return demonstration May need referral for support and community services to provide care, supervision, companionship, respite services, nutritional and ADL assistance, adaptive devices or changes to living environment, financial assistance, etc Met. The client was able to discuss four out of five of wellness program.

Administer medications before activity as needed for pain relief Perform/encourage regular skin examination and care

Encourage adequate intake of fluids/nutritious foods Encourage clients/SOs involvement in decision making as much as possible Discuss safe ways that client can exercise 4. To discuss four out of five of wellness program. Assist client/SO to learn safety measures as individually indicated. Involve client and SO(s) in care, assisting them to learn ways of managing problems of immobility, especially when impairment is expected to be long-term.

Demonstrate use of standing aids and mobility devices and have client/careprovider demostrate knowledge about/safe use of device. Identify appropriate resources for obtaining and maintaining appliances/ equipment.

Safe use of mobility aids promotes clients independence and enhances quality of life and safety for client and caregiver (Nurses Pocket GuideDiagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr p.458-461)