A.

NURSING DIAGNOSIS :

Impaired physical Mobility Related To Loss of integrity of bone structures; decreased muscle
strength or control

B. OUTCOME CRITERIA :
1. Skeletal Function
 Maintain position of function.
 Increase strength and function of affected and compensatory body parts.
2. Mobility
 Regain and maintain mobility at the highest possible level.
 Demonstrate techniques that enable resumption of activities, especially activities
of daily living (ADLs)

C. INTERVENTION :

Bedrest Care
Independent

 Assess degree of immobility produced by injury and/or treatment and note client’s
perception of immobility.
 Encourage participation in diversional or recreational activities.
 Maintain stimulating environment—radio, TV, newspapers,personal possessions,
pictures, clock, calendar, and visitsfrom family and friends.
 Instruct client in active, or assist with passive, ROM exercisesof affected and
unaffected extremities.
 Encourage use of isometric exercises, starting with the unaffected limb.
 Provide footboard, wrist splints, and trochanter or hand rolls,as appropriate.
 Instruct in, and encourage use of, trapeze and “post position”for lower limb
fractures.
 Assist with and encourage self-care activities such as bathing,shaving, and oral
hygiene.
 Assist with mobility by means of wheelchair, walker, crutches,and/or canes as
soon as possible. Instruct in safe use of mobility aids.
 Monitor blood pressure (BP) with resumption of activity. Notereports of dizziness.
  Reposition periodically and encourage coughing and deepbreathing exercises.
 Auscultate bowel sounds. Monitor elimination habits and provide for regular
bowel routine. Place on bedside commode,if feasible. Provide privacy.
 Evaluate client’s prior bowel habits.
 Encourage increased fluid intake of 2000 to 3000 mL/day within cardiac
tolerance, including acid ash juices such ascranberry.
 Provide diet high in proteins, carbohydrates, vitamins, andminerals, limiting
protein content until after first bowelmovement.
 Increase the amount of roughage and fiber in the diet. Limitgas-forming foods.

Collaborative

 Consult with physical or occupational therapist and/or rehabilitation specialist.

 Refer to dietitian or nutrition team, as indicated.
 Initiate bowel program—stool softeners, enemas, or laxatives,as indicated.
 Refer to psychiatric clinical nurse specialist or therapist, as indicated.

D. REFERENCE :

Nursing care plans : guidelines for individualizing client care across the life span / Marilynn
E. Doenges, Mary Frances Moorhouse, Alice C. Murr.—Edition 9.