Assessment Objective: flaccid Bed Ridden restlessness Body weakness

Nursing Diagnosis Impaired physical mobility related to decreased strength and endurance secondary to aneurysm

Planning After 4 hours of nursing intervention the patient will demonstrate technique/behaviors that enable resumption of activities.

Intervention Change the position every 2 hours.

Rationale Reduces risk of tissue injury.

Evaluation After 4 hours of nursing intervention the patient was demonstrate technique/behaviors that enable resumption activities.

Begin Active/passive range of motion to all extremities on admission.

Minimizes muscle atrophy, promotes circulation, and helps prevent contracture.

Assess functional ability/extent of impairment initially and on a regular basis.

Identifies the strength/deficiencies and may provide information regarding to recovery.

observed affect side for color, edema, or other signs of compromised circulation

Edematous tissue is more easily traumatized and heals more slowly.