Document Code No.

CHS/BSN-CURR -RLEFORM-002j
Revision No. Effective Date Page No.
00 02.24.2023 1 of 3

NURSING CARE PLAN

Identified Problem: Impaired physical mobility

Nursing Diagnosis: Impaired physical mobility related to pain and discomfort as evidence by limited range of motion and decreased muscle strength and control
Definition: May refer to NANDA in determining when and when not to use each nursing diagnostic Defining Characteristics:
category, both the definition and defining characteristics should be compared with the client’s set of data
(cues) to make sure that the correct diagnoses are chosen for the client.
Limitation in independent, purposeful movement, of the body or of one or more extremities.

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
"wala koy kusog" as verbalized
by the patient
"di ko comfortable" as
verbalized by the patient
Objective:
- decreased range of motion
- difficulty turning
Short term:
After 4 hours of nursing
intervention, patient will be
able to verbalize
understanding of situation
and individual treatment
regimen and safety measures.
Long term:
After 1 week of nursing
interventions, patient will be
able to:
- demonstrate techniques or
behaviors that enable
resumption of activities
- participate in activities of daily
living and desired activities
1. Evaluate for presence and degree of pain, listening to 1. To determine if pain management can SHORT TERM:
client's description about manner in which pain limits mobility. improve mobility.
GOAL MET:
2. Assess nutritional status and client's report of energy level. 2. Deficiencies in nutrients and water, After 4 hours of
electrolytes, and minerals can negatively affect nursing intervention,
energy and activity tolerance.
3. Note emotional/behavioral responses to problems of patient verbalized
immobility. understanding of
3. Feelings of frustration or powerlessness
may impede attainment of goals. situation and
4. Assist with treatment of underlying condition causing pain individual treatment
and/or dysfunction. 4. To maximize the potential for mobility and regimen and safety
function. measure.
5. Encourage adequate intake of fluids and nutritious foods.
6. Administer medications prior to activity as needed for pain 5. Promotes well-being and maximizes energy
relief. production. LONG TERM:
7. Schedule activities with adequate rest periods during the
6. To permit maximal effect and involvement in
PARTIALLY MET:
activity.
day. Within 3 days of
7. To reduce fatigue. nursing intervention
8. Collaborate with physical medicine specialist and and duty. Patient was
occupational or physical therapies in providing ROM exercise, 8. To develop individual exercise and mobility able to demonstrate
isotonic muscle contractions, assistive devices, activities. program. To identify appropriate mobility some techniques and
devices, and to limit or reduce effects and behaviors that enable
complications of immobility.
9. Identify energy-conserving techniques for ADLSs. resumption of
activities and she also
9. To limit fatigue, maximizing participation. participated in
10. Perform and encourage regular skin examination and
care. 10. To reduce pressure on sensitive areas and
activities of daily living
to prevent development of problems with skin and desired activities.
integrity.
 Document Code No.
CHS/BSN-CURR -RLEFORM-002j
Revision No. Effective Date Page No.
00 02.24.2023 2 of 3
 Document Code No.
CHS/BSN-CURR -RLEFORM-002j
Revision No. Effective Date Page No.
00 02.24.2023 3 of 3

EVALUATION TOOL: NURSING CARE PLAN RUBRIC

Nursing Diagnosis
Risk factors/ Subjective and
Objective Cues
STO and LTO
Nursing Intervention
Evaluation/ Expected Outcome
UNACCEPTABLE SATISFACTORY
(1) (3)
Main Problem is not listed or identified; Identified problem but not the priority
need of the patient;
Assessment data are not listed or inadequate to Correct assessment data but lacking
support nursing diagnosis important factors to support nursing
diagnosis
Objectives do not solve/target the identified problem STO and LTO are not SMART
Intervention/s are not appropriate for the patient and Correct Intervention/s but lacking (5-8
does not solve the main problem (<5 interventions) interventions)
Evaluation or expected outcomes do not measure Evaluation or expected outcomes
the STO and LTO. measure LTO but not the STO.
EXCEPTIONAL
REMARKS
(5)
Main Problem is listed or identified
with correct related factor
Listed all pertinent assessment
data more than enough to support
the nursing diagnosis
STO and LTO are SMART
Intervention/s (>8 interventions)
are correct and appropriate for the
patient.
Evaluation or expected outcomes
measure and target the STO and
LTO.
Total ___/25