Runez, Roscoe B.
03/--/2023
NCC3
Assessment
Subjective: The patient
“Di ako magalaw yung
legs ko. Mejo
nangmamanhid siya.” And
“Pwede po ba ako
magpatulong ayusin yung
higa ko?”
Objective: Guarding
behaviour noted. Facial
grimace noted while
repositioning. Easily tired
while in physical therapy.
Functional level of
mobility is at level 4 –
cannot walk at all and has
no control over lower
extremities. Cannot
achieve ADL
independently.
V/S taken as follows:
 BP 130/80
 O2 98
 CR 78
 CR 24
 T 36.7
Nursing Diagnosis:
Explaination of the
Problem
A modification in
movement or mobility can
either be a transient,
recurring, or more
permanent dilemma. And
when it occurs, it
becomes a complex
healthcare problem that
involves many different
members of the
healthcare team. In fact,
some degree of
immobility is very
common in most
conditions such as stroke,
leg fracture, multiple
sclerosis, trauma, and
morbid obesity. The
incidence of the disease
and disability continues to
expand with the longer
life expectancy for most.
In most cases, even if
patients are discharged
from the hospital earlier
than expected, they are
transferred to
Nursing Care Plan
Planning Intervention/Rationale Evaluation
Short Term: Independent: Short term:
After 8 hours of nursing -Execute passive or active After 8 hours of nursing
intervention, the patient assistive ROM exercises to intervention, the patient
will be able to understand all extremities. Exercise understood the longevity
the longevity of the enhances increased of the diagnosis and
diagnosis present and venous return, prevents demonstrated willingness
demonstrate willingness stiffness, and maintains to participate in physical
to go through physical muscle strength and therapy
therapy stamina. It also avoids
contracture deformation,
Long Term: which can build up quickly Long Term:
After 4-5 days of nursing and could hinder After 4-5 days of nursing
intervention, the patient prosthesis usage. intervention, the patient
will be able to demonstrated different
demonstrate different Dependent: physical therapeutic
physical therapeutic -Assist patient with procedures to help in
procedures to help in muscle exercises as able mobility.
mobility or when allowed out of
bed; execute abdominal-
tightening exercises and
knee bends; hop on foot;
stand on toes. Adds to
gaining an enhanced
sense of balance and
strengthens
compensatory body parts.
-Present a safe
Impaired Physical Mobility rehabilitation facilities or
sent home for physical
therapy.
Aging is also considered
one of the factors
concerning the alteration
in mobility. A decrease in
muscle function, loss of
muscle mass, reduction in
muscle strength, gait
changes affecting balance,
and stiffer and limited
mobile joints can
significantly jeopardize
the mobility of aged
patients. Mobility is
needed especially if an
individual is to maintain
independent living.
Limited movement affects
the performance of most
ADLs. The human body is
designed for motion;
hence, any restriction of
movement will take its toll
on every major anatomic
system thus resulting in
impaired physical
mobility.
environment: bed rails up,
bed in a down position,
and important items close
by. These measures
promote a safe, secure
environment and may
reduce the risk for falls.
Establish measures to
prevent skin breakdown
and thrombophlebitis
from prolonged
immobility:
 Clean, dry, and
moisturize skin as
necessary.
 Use anti-embolic
stockings or
sequential
compression
devices if
appropriate.
 Use pressure-
relieving devices
as indicated (gel
mattress).
 Let the patient
accomplish tasks
at his or her own
pace.