Assessment Diagnosis Planning Intervention Rationale Nursing

consideration
Impaired physical Short term Independent Short term(Goal met)
mobility related to
After 4 hours of Monitor blood Postural hypotension is After 4 hours of
nursing intervention pressure (BP) with the a common problem nursing intervention
the patient will resumption of activity. following prolonged the patient will able
maintain mobility at Note reports of bed rest and may to maintained
the highest possible dizziness. require specific mobility at the
level. interventions (tilt table highest possible
with gradual elevation level.
. to upright position).
.
Long term Teach patient or assist Increases blood flow to
with active and passive muscles and bone to Long term(Goal met)
After 8 hours of ROM exercises of improve muscle tone,
nursing intervention affected and preserve joint mobility; After 8 hours of
the patient will unaffected extremities prevent contractures or nursing intervention
maintain position of atrophy and calcium re- the patient will able
function. absorption from disuse to maintained
position of function.
Isometrics contract
Encourage use of muscles without
isometric exercises bending joints or
starting with the moving limbs and help
unaffected limb. maintain muscle
strength and mass.
Note: These exercises
are contraindicated
while acute bleeding
and edema are present

Useful in maintaining a
Provide footboard, functional position of
wrist splints, extremities, hands, and
trochanter or hand feet, and preventing
rolls as appropriate. complications
(contractures, foot
drop)..

Reposition Prevents or reduces the

periodically and incidence of skin and
encourage coughing respiratory
and deep-breathing complications
exercises. (decubitus,
atelectasis, pneumonia)
.
Dependent

Collaborative

Consult with a
physical, occupational
therapist or Useful in creating
rehabilitation individualized activity
specialist. and exercise program.
Patient may require
long-term assistance
with movement,
strengthening, and
weight-bearing
activities, as well as the
use of adjuncts
(walkers, crutches,
canes); elevated toilet
seats; pickup sticks or
reachers; special eating
utensils.
Refer to psychiatric Patient or SO may
clinical nurse specialis require more intensive
t or therapist as treatment to deal with
indicated. the reality of current
condition, prognosis,
prolonged immobility,
perceived loss of
control