Nursing Diagnosis: Impaired Physical Mobility r/t Pain or discomfort

Cause Analysis: Pain receptors are naked nerve ending found in almost every tissue of the body. Pain is perceived when the tolerance at the site is reached and the
impulses are sent along the sensory pathway to the dorsal root ganglia, then to the spinal cord, after which they cross over into the spinothalamic tract.

(Bullock, B. (1998). Pathophysiology: Adaptations and Alterations in Functions, 4th ed., 655).
Assessment NOC with SMART NIC with interventions Rationale Evaluation
objectives
Subjective: Joint Movement: Active Exercise Therapy: Joint Mobility

Independent:

Patient has difficulty Within the shift, the Implement ROM exercises every shift This prevents joint contracture and muscle Objective is partially
moving because of patient will be able to after pain medication, unless atrophy. met as evidenced by
pain scale of 9/10 as perform ROM exercises. medically contraindicated; progress (Ralph, S. & Taylor, C. (2006). Nursing patient performed ROM
reported by the patient from passive to active as tolerated. Diagnosis Reference Manual, p. 199). exercises on upper
extremities only.
Objective: Reposition patient every 2 hours and To prevent skin breakdown.
provide meticulous skin care. (Ralph, S. & Taylor, C. (2006). Nursing
Grimacing of the face Diagnosis Reference Manual, p. 199).
is observed
Explain the necessity of movement Movement alleviates the effects of
Needs assistance when even during painful periods, unless immobility. Medication alleviates pain
moving contraindicated, to prevent greater and maintains patient’s functional activity
pain such as occurs in arthritic level.
Slow when moving conditions and after surgery. Let (Ralph, S. & Taylor, C. (2006). Nursing
patient know when to expect to move; Diagnosis Reference Manual, p. 199).
Stays flat on bed most provide pain-relief measure before
of the time moving patient.

Instruct patient and family members in Education will enable patient and family
ROM exercises, transfers, skin members to prevent complications of
inspection, and mobility regimen. immobility.
Have patient and family members (Ralph, S. & Taylor, C. (2006). Nursing
return a mobility demonstration under Diagnosis Reference Manual, p. 199).
supervision.

Health Teachings:

Encourage patient to discuss feelings To reduce anxiety and promote

and concerns about his altered state of compliance.
mobility. (Ralph, S. & Taylor, C. (2006). Nursing
Diagnosis Reference Manual, p. 199).

Encourage adherence to other aspects To control or minimize effects of

of health care management.
mobility. This promotes health and well-
being by alleviating pain and preventing
complications.
(Ralph, S. & Taylor, C. (2006). Nursing
Diagnosis Reference Manual, p. 199).