Nursing Diagnosis: Impaired Physical Mobility may be related to decreased strength and endurance due to diminished energy

intake as manifested by:

a. weak spontaneous movements

b. Extremities in some degree of flexion when restraints are removed
c. with poor muscle tone, loose ligaments

Goals of Care Nursing Interventions Rationale Client’s Response

After 8 hours of medical and Independent:
nursing interventions, the client
will be able to: Assessment:

1) Demonstrate improvement • Assess muscle tone, • Provide information • Client demonstrates

in spontaneous strength, mass; joint about musculoskeletal weak spontaneous
movements. mobility, pain, stiffness, condition and function. movement.
swelling; ability to
move. • Maintain stress during
acute stages to promote • Client’s arms were
• Assess bed rest status, healing and restoration restrained to protect his
activity restrictions, and of health. intravenous line.
imposed immobility by •
braces, casts, traction,
splints. • Prevents complications
of immobility by
• Assess physical effects monitoring and
of immobilization on intervening when
body systems; needed; mobility
constipation, skin provides important
breakdown, urinary contributions to
retention, development and
hypercalcemia, loss of physical health.
muscle strength,
contractures, circulatory
stasis, stasis of
pulmonary secretions,
 anorexia, renal calculi,
decreased metabolism
and energy, loss of
nerve innervation. • Client always stays on
the bed.
• Maintains large and
small muscle strength
Therapeutics: as condition permits.

• Provide quiet play and

progress in ambulation by
scheduling dangling at
bedside, standing with • Client is on a supine
support, ambulation with position and placed on
support with increase daily • Prevents fatigue and his crib. Health care
and praise for all attempts conserves energy. team let the baby sleep
regardless of progress. by minimizing their
contact on the baby.
• Coordinate rest with
periods of mobility. • Client is on the bed and
• Promotes mobility his arms are restrained.
according to limitation
Health Teachings: of illness and provides
outlet for frustration of
• Encourage all age – imposed immobility. • Student nurse was not
appropriate activities that able to teach the
facilitate mobility, allow • Maintains muscle and mother because she
infant to crawl. joint function. was not present at that
time.

• Teach parents and child

range of motion,
strengthening exercises as
appropriate.
• Prevents contractures • Client is maintained on
Collaborative: and physical deformity a body alignment on
 and preserves joint bed rest.
Therapeutic: function.

• Maintain body alignment • Any special shoes,

on bed rest, reposition
every 2 hours or as • Maintains position at
needed. night and prevents
deformity.
• Apply special shoes, splint,
or appliance for day or
night use.
• Promotes compliance
Health Teachings: with prescribed therapy
especially if needed to
• Reinforce parents and child ensure mobility or
of importance of therapy health maintenance in
and follow – up care, short chronic disorders.
or long – term depending
on need. • Promotes compliance
with program to
maintain mobility and
• Inform parents and child of understanding of effects
hazards of immobility. of mobility.
splints or appliance
were not noted.
• Student nurse was not
able to reinforce the
importance of therapy
to the mother because
she was not present at
that time.
• Student nurse was not
able to inform the
mother because she
was not present at that
time.

General Evaluation:

After 8 hours of medical and nursing interventions, the client demonstrated weak spontaneous movement.