Nursing Care Plan : Identified Nursing Problem: Impaired Physical Mobility related to activity intolerance, musculoskeletal impairment, limited strength, and pain/discomfort.

Scientific Basis:

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative state involve some degree of immobility (e.g., leg fracture, trauma).

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobility joint, and gait changes affecting balance can significantly compromise the mobility of older clients.

Mobility is paramount if the older clients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Older client 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.

Gulanick, 2007



Intervention and Rationale

I: Assess for impediments to immobility.
R: Identify the specific cause guides design of an optimal treatment plan.

I: Assess the client’s ability to perform ADLs effectively and safely on a daily basis using an appropriate assessment tool, such as the functional independence measures (FIM).
R: Restricted movement affects the ability to perform most ADLs. A variety of assessment tools are available, depending on the clinical setting. Such tools provide objective data for baselines.

I: Assess ability to ability to perform ROM to all joints.
R: This provides baseline measurement for future evaluation and guides therapy. Testing by a physical therapist may be needed.

I: Assess the client’s and caregiver’s knowledge of immobility and it’s implications.
R: Even the clients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression.

I: Assess for developing thrombophlebitis (e.g., calf pain Homan’s sign, redness, localized swellings, and rise in temperature).
R: Bed rest or immobility promotes clot formation.

I: Assess skin integrity. Check for sign of redness and tissue ischemia.
R: Regular examination of the skin (especially over bonny prominences) will allow for prevention or early recognition and treatment of pressure sores.

I: Monitor input and output record and nutritional pattern. Assess nutritional needs as they relate to immobility.
R: Pressure sores develop more quickly in clients with nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or rehabilitative program.

I: Assess elimination status (e.g., usual pattern, present patterns, signs of constipation).
R: Immobility promotes constipation.

I: Assess emotional response to disability or limitation.
R: Acceptance of temporary or more permanent limitations can vary widely among individuals. Each person has his or her own definition of acceptable quality of life.

I: Evaluate need for home assistance.
R: Obtaining appropriate assistance for client can ensure safe and proper progress of activity.

I: Evaluate the safety of the immediate environment.
R: Obstacles such as throw rugs, can further impede one’s ability to ambulate safely.

I: Encourage and facilitate early ambulation and other ADLs when possible. Assist in initial change: dangling legs, sitting in chair, ambulation.
R: The sooner the client becomes mobile, the less chance that debilitation will occur.

I: Provide positive reinforcement during activity.
R: Clients may be reluctant to move or initiate new activity due to fear of falling. A positive approach allows the learner to feel good about learning accomplishments.

I: Allow the client to perform tasks at his own rate. Do not rush the client. Encourage independent activity as able and safe.
R: Health care team and family care givers are often in hurry and do more for clients than needed, thereby slowing the client’s recovery and reducing his self-esteem.

I: Encourage to turn every 2 hours as needed.
R: Turning the clients optimizes circulation to all tissue and relieves pressure.

I: Perform passive or active ROM exercise to all extremities.
R: Exercise promotes increased venous return, prevents stiffness, and maintain muscle strength and endurance. To be most effective, all joints should be exercised to prevent contractures.

I: Encourage resistance training exercise using light weights when appropriate.
R: 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.

I: Encourage liquid intake of 2000 to 3000 ml/day unless contraindicated.
R: Liquids optimize hydration status and prevent hardening of the stool.

I: Teach energy-saving techniques.
R: These optimize the client’s limited reserves.

I: Assist the client in accepting limitations. Emphasize abilities.
R: Quality of life is influenced by a variety of factors that can extend beyond only physical function.
I: Explain progressive activity to the client. Help the client or caregivers establish reasonable and obtainable goals.
R: Information promotes awareness of the treatment plan. Setting small, attainable goals help increase self-confidence and promotes adherence.

I: Instruct the client or caregivers regarding hazards of immobility. Emphasize importance of measures such as position change, ROM, coughing, and exercise.
R: Information enables the client to assume some control over rehabilitation process.

I: Reinforce principles of progressive exercise, emphasizing that joints are to be exercised to the point of pain, not beyond.
R: “no pain, no gain” is not always true.

I: Instruct the client and family regarding the need to make the home environment safe.
R: A safe environment will help prevent injury related to falls.

Gulanick, 2007; Doenges, et al, 2002; Kruse, et al, 2003