NUR 100 Week 7

NSG Dx RT Movement and Immobility Lecture 11.15.20

Common North American Nursing Diagnosis Association International (NANDA-I) nursing diagnoses directly associated
with immobility include:

 Impaired Physical Mobility  Impaired Wheelchair Mobility

 Impaired Bed Mobility  Impaired Transfer Ability
 Impaired Ambulation
Common International Classification for Nursing Practice (ICNP) nursing diagnoses associated with immobility are:

 Impaired Mobility
 Risk for Fall
 Activity Intolerance

Mobility Impaired RT AEB:

Physical  s/p hip  inability to ambulate independently
Mobility fracture,  pain with movement
 limited ROM
Falls Risk for Falls w RF of
 altered mobility
 secondary to
cerebrovascula
r accident.
Activity Activity RT AEB:
Intolerance  the  shortness of breath
deconditioning  oxygen saturation below 90%
effects of bed  pulse rate above 100 with activity.
rest
Constipation Constipation RT AEB
 decreased  patient report of no BM x 3 days
peristalsis  abdominal distention
 secondary to  hypoactive BS
immobility
Skin Impaired RT AEB
Skin Integrity  ischemia  reddened area on left heel
 softened left heel tissue
 bed rest restriction
Social Social RT AEB
Isolation Isolation therapeutic treatment,  patient stating, “I feel lonely. No one
comes to visit, and I can’t get out of bed”
 patient appearing anxious
 patient being unable to complete ADLs
independently.

NSG Dx Goal
1
 NUR 100 Week 7
NSG Dx RT Movement and Immobility Lecture 11.15.20

Ambulation Impaired RT AEB:  Patient will ambulate with

Physical  s/p hip fracture  inability to ambulate the assist of one caregiver
Mobility independently within 24 hours.
 pain with movement
 limited range of motion.
Risk for Risk for Falls w RF  Patient will experience no
Falls  altered mobility falls during hospitalization.
 secondary to CVA
Activity Activity RT AEB:  Patient will be able to
Tolerance Intolerance  deconditioning  shortness of breath, ambulate 25 feet in the hall
effects of bed rest oxygen saturation below without complaints of
90% fatigue or shortness of
 pulse rate above 100 with breath.
activity.
Nutrition Imbalanced RT AEB  Patient will consume 50%
Nutrition:  decreased desire to  dietary intake of less than of the diet each day.
Less than eat 30%,
Body  patient stating, “I just
Requirement don’t feel like eating,”
s  muscle weakness
 weight loss.
Bowel Constipation RT AEB  Patient will have daily
Function  decreased peristalsis  patient report of no bowel bowel movements.
 secondary to movement for three days
immobility  abdominal distention
 hypoactive bowel sounds

Key Points
 Nursing diagnoses related to movement and immobility are selected after reviewing objective and subjective
assessment findings.
 In order for the nurse to select and individualize the most appropriatenursing diagnoses, the nurse must:
o Use detailed interviewing techniques to obtain subjective data of the patient’s complaints or statements
regarding movement or immobility.
o Use observation to develop an overall impression of the patient, including the patient’s ability to move
or need for assistance.
 Common nursing diagnoses related to movement and immobility include Impaired Physical mobility, Risk for
Falls, and Activity Intolerance.
 The most important aspect of collaboration in planning patient care related to movement and immobility are:
o Planning involves collaboration with patients, families, and members of the health care team.
o Determining realistic, measurable, patient-centered goals is essential to the plan of care for the
immobile patient.