Group I (Mobilization)

Member of the group:

1. Cahyany Prayitno 6. Mega Purnamasari

2. Dita Oktaviani 7. Rosichan Anwar Al Muluk
3. Gina Indah Aulia 8. Saeful
4. Indah Ayu Lestari Hidayatullah 9. Siti Fazriyanti
5. Lusi

 Case
You are a nurse in medical surgical unit in a hospital caring for a 68 years old brick mason
who returned to your floor after surgery to repair both knees 2 days ago. The surgery went
smothly and you responsible for his postoperative care.

 Nursing Care Plan

DS : -

DO : - Mr. weng 68 y.o after surgery to repair both knees 2 days ago

- The clients movement appear to be very limited due to the after surgery to repear
both knees 2 days ago

- Vital Sign: Blood pressure: 120/80 mmHg, pulse : 80x/minutes, respiratory:

18/minutes, temperature : 37 degree celcius

Nursing Diagnosis:

Mobility: Physical, Impaired

Nursing Outcome Clasification:

1. Mobility
a. Muscle movement : 3 (moderately cpmpromised)
b. Body position performance : 3 (moderately cpmpromised)
2. Activity Tolerance
a. Upper body strength : 5 (no compromised)
b. Lower body strength : 3 (moderately cpmpromised)

Nursng Care Plan:

1. Positioning:
a. Encourage active or passive range of motion exercise, as appopiate
b. Avoiding placing a patient in a position that increase pain
c. Elevate affected limb 20 degrees or greater, above the level of the heart, to
improve venous return, as appropiate
2. Exercise therapy: muscle control
a. Initiate pain control measures before beginning exercise / activity
 Implementation Strategy
Implementation Strategy
(Meeting 1, Monday, May 18th 2019)
A. Nursing Process
1. Client’s condition:
DS : -
DO : - Mr. weng 68 y.o after surgery to repair both knees 2 days ago
- The clients movement appear to be very limited due to the after surgery to
repear both knees 2 days ago
- Vital Sign
Blood pressure: 120/80 mmHg, pulse : 80x/minutes, respiratory: 18/minutes,
temperature : 37 degree celcius

2. Nursing Diagnosis:
Mobility: Physical, Impaired

3. Purpose:
Teach the patient’s range of motion and muscle strength postoperative

4. Nursing Action:
Range Of Motion : Passive

B. Orientation Phase
1. Greeting Therapeutic
“Hello good morning mr weng, my name is nurse indah, I’m nurse on duty today from
7 am until 2 pm”
“what is your name?”
“how old are you mr. ?”

2. Evaluation/Validation
“How are you feeling today?”
“Do you have any complains?”
 3. Contract
“Today I’m going to teach you how to move and strengthen of muscles in your feet it’s
about 10 minutes, were doing in here, do you agree mr?”
“The purpose is to exercise the patient’s range of motion and muscle strength
postoperative”

C. Working Phase
“okay mr, I’m going to teach you how to move and strengthen of muscles in your feet,
first I’m going to change your position to make you comfortable, are you comfortable
now? Next, I’m going to move the right f your feet outward, followed by the left feet, then
stretch part of the feet will be rotated outward and inward on the right feet and left feet,
then bend the sole of the feet up and down and repeated on the left feet”. I will help stretch
your toes by using my fingers and followed by the left feet, next I’m going to put a pillow
under your ankle.”

D. Termination Phase
1. Subjective Evaluation
“How are you felling after I teach you how to move and strength of muscles in your
feet?’’
2. Objective Evaluation
“Can you repeat the prsedure by yourself mr. weng?’’
3. Follow up plan
“okay mr, This ROM exercise can be repeated 8 times and do it at least 2 times day to
mr. weng’’.
4. Upcoming Contract
“okay if you need me you can call me or press the button. And I will come back an 11
hour to check on your conditon with the doctor. Take a rest Mr.’’
 ISBAR
(I)dentifity : “Good morning dr. rina, this is Nurse Indah. I am calling about your
patient Mr. weng on jasmine Room 601”

(S)ituation : “Mr. weng is a 68yo, male, he underwent knee surgery for both knees.
The patient diagnosed with a barrier to physical mobility.”

(B)ackground :”The clients movement appear to be very limited due to the after
surgery to repear both knees 2 days ago.”

(A)sessment : “I think Mr. weng is exhibiting symtomps that maybe associated with
Impaired mobility physical”

(R)ecomendation : “dr. rina, will you be coming to see the patient? Or would you like to
recommended to contact fisiptheraphy for your patient?