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Nursing Care of the Pediatric Neurosurgery Patient

NCP Nursing Diagnosis: Impaired Physical Mobility Immobility
44Share 0diggsdigg Nursing Diagnosis: Impaired Physical Mobility Immobility NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels * Ambulation: Walking * Joint Movement: Active * Mobility Level NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels * Exercise Therapy: Ambulation * Joint Mobility * Fall Precautions * Positioning * Bed Rest Care NANDA Definition: Limitation in independent, purposeful physical movement of the body or of one or more extremities Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree 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 facilities or sent home for physical therapy in the home environment. Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. 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 additional impairment of physical activity, and ensure a safe environment. * Defining Characteristics: Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation * Reluctance to attempt movement * Limited range of motion (ROM) * Decreased muscle endurance, strength, control, or mass * Imposed restrictions of movement including mechanical, medical protocol, and impaired coordination * Inability to perform action as instructed * Related Factors: Activity intolerance * Perceptual or cognitive impairment * Musculoskeletal impairment * Neuromuscular impairment * Medical restrictions * Prolonged bed rest * Limited strength * Pain or discomfort * Depression or severe anxiety

* Expected Outcomes Patient performs physical activity independently or with assistive devices as needed. * Patient is free of complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, and normal bowel pattern. Ongoing Assessment * Assess for impediments to mobility (see Related Factors in this care plan). Identifying the specific cause (e.g., chronic arthritis versus stroke versus chronic neurological disease) guides design of optimal treatment plan. * Assess patient s ability to perform ADLs effectively and safely on a daily basis. Suggested Code for Functional Level Classification 0 Completely independent 1 Requires use of equipment or device 2 Requires help from another person for assistance, supervision, or teaching 3 Requires help from another person and equipment or device 4 Is dependent, does not participate in activity Restricted movement affects the ability to perform most ADLs. Safety with ambulation is an important concern. * Assess patient or caregiver s knowledge of immobility and its implications. Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression. * Assess for developing thrombophlebitis (e.g., calf pain, Homans sign, redness, localized swelling, and rise in temperature). Bed rest or immobility promote clot formation. * Assess skin integrity. Check for signs of redness, tissue ischemia (especially over ears, shoulders, elbows, sacrum, hips, heels, ankles, and toes). * Monitor input and output record and nutritional pattern. Assess nutritional needs as they relate to immobility (e.g., possible hypocalcemia, negative nitrogen balance). Pressure sores develop more quickly in patients with a nutritional deficit. Proper

nutrition also provides needed energy for participating in an exercise or rehabilitative program. * Assess elimination status (e.g., usual pattern, present patterns, signs of constipation). Immobility promotes constipation. * Assess emotional response to disability or limitation. * Evaluate need for home assistance (e.g., physical therapy, visiting nurse). * Evaluate need for assistive devices. Proper use of wheelchairs, canes, transfer bars, and other assistance can promote activity and reduce danger of falls. * Evaluate the safety of the immediate environment. Obstacles such as throw rugs, children s toys, and pets can further impede one s ability to ambulate safely. Therapeutic Interventions * Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation. The longer the patient remains immobile the greater the level of debilitation that will occur. * Facilitate transfer training by using appropriate assistance of persons or devices when transferring patients to bed, chair, or stretcher. * Encourage appropriate use of assistive devices in the home setting. Mobility aids can increase level of mobility. * Provide positive reinforcement during activity. Patients may be reluctant to move or initiate new activity due to a fear of falling. * Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe. Hospital workers and family caregivers are often in a hurry and do more for patients than needed, thereby slowing the patient s recovery and reducing his or her self-esteem. * Keep side rails up and bed in low position. This promotes a safe environment. * Turn and position every 2 hours or as needed. This optimizes circulation to all tissues and relieves pressure. * Maintain limbs in functional alignment (e.g., with pillows, sandbags, wedges, or prefabricated splints). This prevents footdrop and/or excessive plantar flexion or tightness. Support feet in dorsiflexed position.

Use bed cradle. This keeps heavy bed linens off feet. * Perform passive or active assistive ROM exercises to all extremities. Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength and endurance. * Promote resistance training services. Research supports that strength training and other forms of exercise in older adults can preserve the ability to maintain independent living status and reduce risk of falling. * Turn patient to prone or semiprone position once daily unless contraindicated. This drains bronchial tree. * Use prophylactic antipressure devices as appropriate. This prevents tissue breakdown. * Clean, dry, and moisturize skin as needed. * Encourage coughing and deep-breathing exercises. These prevent buildup of secretions. Use suction as needed. Use incentive spirometer. This increases lung expansion. Decreased chest excursions and stasis of secretions are associated with immobility. * Encourage liquid intake of 2000 to 3000 ml/day unless contraindicated. Liquids optimize hydration status and prevent hardening of stool. * Initiate supplemental high-protein feedings as appropriate. If impairment results from obesity, initiate nutritional counseling as indicated. Proper nutrition is required to maintain adequate energy level. * Set up a bowel program (e.g., adequate fluid, foods high in bulk, physical activity, stool softeners, laxatives) as needed. Record bowel activity level. * Administer medications as appropriate. Antispasmodic medications may reduce muscle spasms or spasticity that interfere with mobility. * Teach energy-saving techniques. These optimize patient s limited reserves. * Assist patient in accepting limitations. Emphasize abilities.

Education/Continuity of Care * Explain progressive activity to patient. Help patient or caregivers to establish reasonable and obtainable goals. * Instruct patient or caregivers regarding hazards of immobility. Emphasize importance of measures such as position change, ROM, coughing, and exercises. * Reinforce principles of progressive exercise, emphasizing that joints are to be exercised to the point of pain, not beyond. "No pain, no gain" is not always true! * Instruct patient/family regarding need to make home environment safe. A safe environment is a prerequisite to improved mobility. * Refer to multidisciplinary health team as appropriate. Physical therapists can provide specialized services. * Encourage verbalization of feelings, strengths, weaknesses, and concerns. Posted by---at20:25