NCM104b BSN220/Group 8 0 Cues Nursing Diagnosis Analysis Planning Interventio n Rationale Evaluation Subjective: Ang hirap ng may ganito

(traction). Bawal kumilos, hindi man lang ako makapunta s a banyo para maligo. Hinihintay ko pa na may bisita ako para lang makapaglinis ng sarili ko verbalized by the client. Objective: Client is on modified bucks extension traction. Client is on semi- fowlers position. Client had fracture on the proximal 3rd of his left femur due to gunshot. Client had three gunshots on his abdomen with mainly his duodenum and jejunum as well as in his right leg. Provisional Diagnosis: Hypovolemic shock 2 to multiple GSW Measurement: Red Blood Cells 3.77 x 10^12/L Impaired Physical Mobility related to musculoskeletal impairment possibly evidenced by in ability to move purposefully within the physical environment, imposed restriction. Impaired Physical Mobility Limitation in independent, purposeful physical movement of the body or of one or more extremities. (Nurses Pocket Guide-Diagnoses, Prioritized Intervent ions, and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr p.457) Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some d egree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis ). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation Goals: After 8 hours of nursing intervention, the client will be able to verbalize unde rstanding of situation and individual treatment regimen and safety measures inde pendently. Objectives: After 1 hour of nursing intervention, the client will be able to: 1.To identify at least five out of eight causative/contributing factors

Determine diagnosis that contributes to immobility

Note factors affecting current situation and potential time involved.

Assess clients developmental level, motor skills, ease and capability of movement , posture and gait. Note older clients general health status

These conditions can cause physiological and psychological problems that can ser iously impact physical, social, and economic well-being. Identifies potential impairments and determines type of interventions needed to provide for clients safety To determine presence of characteristics of clients unique impairment and to guid e choiceofinterventions Identified mobility as the most important functional ability that determines the degree of independence and healthcare needs among older persons.2 While aging per se does not cause impaired mobility, several The goal was met.

Met. The client was able to identify five out of eight causative/contributing fa ctors. Normal Findings: (Males) 5.5-6.5 x10^12/L Hemoglobin 11.80 g/dL Normal Findings: (Males) 14-16 g/dL Hematocrit 0.33 L/L Normal Findings: (Males) 0.42-0.52 L/L Lymphocytes 0.21 Normal Findings: 0.25-0.35 Eosinophils 0.01 Normal Findings 0.03-0.05 facilities or sent home for physical therapy in the home environment. Mobility is also related to body changes from aging. Loss of muscle mass, reduct ion in muscle strength and function, stiffer and less mobile joints, and gait ch anges affecting balance can significantly compromise the mobility of elderly pat ients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additio nal impairment of physical activity, and ensure a safe environment. (Nursing Care Plans: Nursing Diagnosis and Intervention by Gulanick, Myers,

2.To report three out of five of his functional ability

Evaluate for presence/degree of pain, listening to clients description about mann er in which pain limits mobility. Ascertain clients perception of activity/exercise needs and impact of current sit uation. Identify cultural beliefs and expectations affecting recovery/response to long-t erm limitations. Assessnutritionalstatusand clientsreportofenergylevel.

Determinehistoryoffallsand relatednesstocurrentsituation.

Determine degree of immobility in relation to 04 scale, noting muscle strength and tone, jointmobility,cardiovascular status,balance,andendurance.

Determinedegreeof perceptual/cognitiveimpairment andabilitytofollowdirections predisposing factors inadditiontoage-relatedchanges canleadtoimmobility Todetermineneededinterventions forpainmanagement

Helps to determine clients expectations/beliefs related to activity and potential long-term effectofcurrentimmobility.Also identifiesbarriersthatmaybe a ddressed

Deficiencies in nutrients and water,electrolytesandminerals cannegativelyaffecte nergyand activitytolerance. Client may be restricting activity because of weakness/debilitation, actual inju ry during a fall, or from psychological distressthatcanpersistafterafall. Identifies strengths and deficits impaired physical mobility and may provide information regarding potential for recovery Impairments related to age, chronic or acute disease condition, trauma,

Met. The client was able to report three out of five of his functional ability. Klop, Galanes, Gradishar and Puzas)

Observemovementwhenclient isunawareofobservation Noteemotional/behavioral responsestoproblemsof immobility

Determinepresence of complicationsrelatedto immobility surgery, or medications require alternative interventions or changes in plan of care. To note any incongruence with reportsofabilities. Can negatively affect self- concept and self-esteem, autonomy, and independence. Feelings of frustration and powerlessness may impede attainment of goals. Social, occupational, and relationship roles can change, leading to isolation, depression, and economic co nsequences Studies have shown that as much as 5.5% of muscle strength can be lost each day of rest and immobility.5 Other complications include changes in circulation and impairments of organ function affecting the whole person 3.To explain at least five of the optimal level of function and measures on how to prevent complications. Assistwithtreatmentof underlyingcondition(s)

Discuss discrepancies in movement with client aware and unaware of observation a nd methodsfordealingwith identifiedproblems. Assist/haveclientrepositionself To maximize potential for mobility and optimal function. May be necessary when client is using avoidance or controlling behavior, or is not aware of own abilities due to anxiety/fear. To enhance circulation to Met. The client was able to explain at least five of the optimal level of functi on and measures on how to prevent complications. onaregularscheduleasdictated byindividualsituation Review/encourageuseofproper bodymechanics Demonstrate/assistwithuseof siderails,overhead trapeze,roller pads,hydrauliclift s/chairs Supportaffected body parts/jointsusingpillows/rolls, footsupports/shoes,gelpads, etc., Provide/recommend egg-crate, alternatingair-pressure, orwater mattress. Usepaddingandpositioning devices

Encourage clients participation in self-care activities, physical/occupational th erapies as well as diversional/recreational activities. Provide client with ample time to perform mobility-related tasks. Schedule activ ities with adequaterestperiodsduringthe day Avoidroutinelyassistingor doingforclientthoseactivities thatclientcandoforself. Identify/encourageenergy- conservingtechniquesfor tissues, reduce risk of tissue ischemia. Topreventinjurytoclientand caregiver Forpositionchanges/transfers. Instructinsafeuseofwalker/cane forambulation. Tomaintainpositionoffunction andreduce riskofpressureulcers. Reduces tissue pressureandaidsinmaximizing cellularperfusiontopreventdermal inju ry. To prevent stress on tissues and reduce potential for disusecomplications. Reduces sensory deprivation, enhances self- concept andsenseofindependence,and i mprovesbodystrengthand function. Toreducefatigue.

Caregivers cancontributetoimpairedmobility bybeingoverprotective orhelping toomu ch. Limits fatigue, maximizing ADLs. Notechangeinstrengthtodo moreorlessself-care

Administermedicationsbefore activityasneededforpainrelief Perform/encourageregular skin examinationandcare

Encourageadequate intakeof fluids/nutritiousfoods Encourageclients/SOs involvementindecisionmaking asmuchaspossible participation. To promote psychological and physical benefits of self-care and to adjust level of assistance asindicated. To permit maximal effort/involvementinactivity. To reduce pressure on sensitive areas and to prevent development of problems wit h skin integrity. Promotes well-being and maximizes energy production. Enhances commitment to plan, optimizing outcomes.

4.To discuss four out of five of wellness program. Discusssafewaysthatclientcan exercise Assistclient/SOtolearnsafety measuresasindividually indicated. Involve client and SO(s) in care, assisting them to learn ways of managing probl ems of immobility,especiallywhen impairmentisexpected tobe long-term. Multipleoptionsprovideclient choicesandvariety

May need instruction and to givereturndemonstration May need referral for support and community services to provide care, supervisio n, companionship, respite services, nutritional and ADL assistance, adaptive devices or changes to living environment, financial assistance, etc

Met. The client was able to discuss four out of five of wellness program. Demonstrate use of standing aids and mobility devices and have client/careprovid er demostrate knowledge about/safe use of device. Identify appropriate resources for obtaining and maintaining appliances/ equipment. Safe use of mobility aids promotes clients independence and enhances quality of l ifeandsafetyforclientand caregiver (Nurses Pocket Guide- Diagnoses, Prioritized Interventions, and Rationales by M arilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr p.458-461)