Impaired physical mobility Nursing care plan

How to complete Impaired physical mobility Nursing care plan

Impaired physical mobility TEMPLATE

STUDENT’S NAME:                                                                        CLINICAL UNIT: NEURO

 

DATE OF PATIENT CARE:                         CLINICAL INSTRUCTOR:

1. DEMOGRAPHIC DATA:

Patient Initials:  GM Age:  Gender: Male    Date of Admission:    Disposition (DNR/Full Code): CPR

HISTORY OF PRESENT ILLNESS:

GM was brought to the hospital after being involved in a bar fight with a friend. The patient was hit on the back of his head and hit the ground. He was intoxicated during the ordeal and had to be brought in by two friends.

DIAGNOSIS:  Impaired physical mobility related to neuromuscular impairment as evidence by right sided weakness.

ALLERGY:      N/A                                    REACTION:  N/A

1. PAST MEDICAL/ PSYCHIATRIC HISTORY (Include date condition was diagnosed, if known):
2. PAST SURGICAL HISTORY (Include dates of surgery, if known):

III. PSYCHOSOCIAL HISTORY:

Spiritual/ Cultural Assessment

Reproductive Assessment

     Menstrual assessment

LNMP: N/A

Smoking:

Recreational Drug us:

Influenza Vaccination:

Pneumovax:

Discharge Planning:

Support Systems:

Living arrangements:

Caregiver:

Referral Needs:

Medication Compliance Issues (literacy/language barrier etc.):

1. VITAL SIGN

BP-     Heart Rate –   Heart Rhythm – Atrial Fibrillation: ,    Respiratory Rate:  ,          Temp. –,  O2 Sat –

1. PAIN (Provide a complete description):

1. Lab Values: Date of Result 9/25/22   (indicate if value is high or low):

Hemoglobin –14:

Na – 139:

BUN – 18:

PT – 9:

Hematocrit – 44%:

K –   4.0:

Creatinine –  1:

INR -1.1:

WBC – 13,000:

CO₂ – 26: Normal

Glucose – 132:

PTT – 26:

Platelets – 200,000:

CL –        101:

Fingerstick –  26:

Albumin – 3.6:

Magnesium –    2.2:

Calcium – 9.9

Others: N/A

VII – Patient’s Medications (Include ALL medication the patient is taking, even if you did not administer. Use another sheet if needed)

 

Medication (as ordered by M.D./NP) – Classification – How does the medication work (Chemical action)?

Reason For Taking Them? (Example: To treat Hypertension and CHF)

Side Effects, contraindications and lab values to be monitored (Only specific/important ones. Label items as below)

Patient and Family Teaching (Only specific instruction for that drug) Never write: Take as directed

 

VIII. Nursing Care Plan – Provide any three nursing diagnosis.

Nursing Diagnosis (What’s your patient’s most acute problem?

Objectives / Goals SMART criteria (Relate to your diagnosis)

Interventions (Minimum three, start with non-pharmacological care)

Rationale (Evidenced Based reasons for your interventions)

Evaluation (How do you know your interventions worked?)

 

1. Assessment Tools

Please provide the specific score for each of the following assessment tools and briefly state the significance of the score.

• Braden Score:
• Katz ADL Assessment:
• Hendrich II Fall Risk:

• Mini Cog (optional):

Note: If not able to assess, please write “unable to assess” and provide an explanation

 

SOLUTION: Impaired physical mobility Nursing care plan

 

STUDENT’S NAME:                                                                        CLINICAL UNIT: NEURO

 

DATE OF PATIENT CARE: 10/04/2023                CLINICAL INSTRUCTOR:

1. DEMOGRAPHIC DATA:

Patient Initials:  GM Age: 52 , Gender: Male    Date of Admission: 9/04/2023    Disposition (DNR/Full Code): CPR

HISTORY OF PRESENT ILLNESS:

GM was brought to the hospital after being involved in a bar fight with a friend. The patient was hit on the back of his head and hit the ground. He was intoxicated during the ordeal and had to be brought in by two friends. This happened two week ago.

DIAGNOSIS:  Impaired physical mobility related to neuromuscular impairment as evidence by right sided weakness.

 

ALLERGY:      N/A                                    REACTION:  N/A

 

1. PAST MEDICAL/ PSYCHIATRIC HISTORY (Include date condition was diagnosed, if known):

The patient’s past medical history indicate that he has hypertension, neuromuscular disease, atrial fibrillation, and was involved in an accident 10 years ago where he suffered a spinal cord injury.

1. PAST SURGICAL HISTORY (Include dates of surgery, if known):

No known history of surgery

III. PSYCHOSOCIAL HISTORY:

Spiritual/ Cultural Assessment

Religion:   Muslim

Cultural/Ethnic background: Russian

Reproductive Assessment

Sexual orientation: Straight

Marital status: Married

     Menstrual assessment

LNMP: N/A

Smoking: Has been smoking cigarette for the last 20 years. He smokes 45 packs per year.

Recreational Drug us: Takes alcohol occasionally

Influenza Vaccination:  No

Pneumovax: No

Discharge Planning:

Support Systems: Discharge planning should include activities that will support the patient in ambulation, transferring, and movement in bed.

Living arrangements: _The patient should be encouraged to live downstairs to avoid risk for falls as one walks upstairs. Caregiver: A caregiver, especially the wife will provide the much needed support at home.     Referral Needs: No need for referral

Medication Compliance Issues (literacy/language barrier etc.): the patient is literate and understands well the importance of medication compliance.

1. VITAL SIGNS

BP- 165/87,     Heart Rate –   121 /min,       Heart Rhythm -105bpm,    Atrial Fibrillation: 138bpm,    Respiratory Rate:  20   /min,          Temp. – 101 F , O2 Sat –    95 %

1. PAIN (Provide a complete description): Sudden, sharp, and stabbing pain on his right side feet. 

1. Lab Values: Date of Result 9/25/22   (indicate if value is high or low):

Hemoglobin –14: Normal (Normal range 14-18g/dl)

Na – 139: Normal (Normal range136-145milimoles per liter)

BUN – 18: Normal (Normal range is 6-24mg/dL).

PT – 9: Low (Normal values 10-13 seconds)

Hematocrit – 44%: Normal (Normal range 40-54%)

K –   4.0: Normal (Normal range 3.5-5.2 mmol/L

Creatinine –  1:  Normal (Normal range 0.7-1.3 mg/dL).

INR -1.1: Normal (Normal range is 1.1 and below)

WBC – 13,000: High (Normal range 4500-11000 WBCs per microliter

CO₂ – 26: Normal (Normal range 23-30 mEq/L).

Glucose – 132:  high   (Normal values 70-100mg/dL).

PTT – 26: Normal (Normal values 25-35).

Platelets – 200,000: Normal (Normal range 150000-400000 platelets per microliter

CL –        101: Normal (Normal range 96-106 miliequivalent per liter

Fingerstick –  26: Low (Normal range 70-100mg/dL).

Albumin – 3.6: Normal (Normal range 3.4-5.4 g/dL).

Magnesium –    2.2: high (Normal 1.7-2.1 mg/dL).

Calcium – 9.9    Normal (Normal range 8.6-10.3 mg/dL).

Others: N/A

Height: 5ft 10 inches Weight: 160pds BMI (Compute based on patient’s height and weight): 22.96

 

VII – Patient’s Medications (Include ALL medication the patient is taking, even if you did not administer. Use another sheet if needed)

 

Medication (as ordered by M.D./NP) – Classification – How does the medication work (Chemical action)?	Reason For Taking Them? (Example: To treat Hypertension and CHF)	Side Effects, contraindications and lab values to be monitored (Only specific/important ones. Label items as below)	Patient and Family Teaching (Only specific instruction for that drug) Never write: Take as directed
Trade name: Enalapril Generic name: Vasotec Classification: Angiotensin converting enzyme (ACE) inhibitors Mode of action: The medication works by blocking substances in the body that cause blood vessels to tighten. This result in the relaxation of blood vessels, lowers blood pressure, and increases supply of oxygenated blood to the heart and other body parts.	To reduce blood pressure	Side effects: Common side effects include hypotension, rapid fall in blood pressure, headache, dizziness, neutropenia, nausea, and stomach pain. Contraindication: the medication should be avoided in patients with aortic stenosis, stroke, hypertrophic cardiomyopathy, renal artery stenosis, and renal impairment. Lab values: Some of lab values to be monitored include renal functioning, serum potassium levels, BUN, complete blood count, hypotension, and blood pressure.	·    Educate the patient how to identify adverse events such as hypotension, changes in skin colour, and turgor, and when to report to their primary care provider. Educate the patient to avoid over the counter medications especially cough and cold medications as they may interact with enalapril.
Trade name: Flecainide Generic name: Sotalol Classification: Beta Blocker Mode of action: Flecainide works on fast-inward Na ion channels, prolongs depolarization, and increases refractoriness due to slow release from its binding site.	To treat irregular heart rhythm, shortness of breath, and atrial fibrillation	Side effects: Common serious side effects include dizziness, blurred vision, headache, muscle weakness, stomach pain, and constipation. Contraindications: The drug is contraindicated in patients using fluconazole, HIV protease inhibitors, and anti-seizure medications. Lab values: Nurses should monitor the fasting blood glucose, blood pressure, serum concentration, and ketone levels to assess the effectiveness of the medication	·    Educate the patients using sustained-release tablets to swallow whole and not chew or crush. ·    Nurses should educate the patient on the need to withdraw the medication immediately in case of acidosis. Educate the patient not to use alcohol since it increases the risk for lactic acidosis and acute renal failure.
Generic Name: Morphine Sulfate Brand Names: Arymo ER, Kadian, MorphaBond ER, MS Contin Classification: Opioid agonists Mode of action: Binds to the mu-opioid receptor within the central nervous system and the peripheral nervous system thereby producing its analgesic effect.	To treat chronic pain due to spinal cord injury and impaired mobility caused as a result of a fall.	Side effects: The common adverse effects of the drug include constipation, central nervous system depression, nausea, skin rash, urticarial, bradycardia, vomiting, urinary retention, respiratory depression, sedation, dizziness, euphoria, agitation, dry mouth, anorexia, hypotension, and right upper quadrant pain. Contraindications: contraindicated in patients with hypersensitivity to morphine and morphine extended release medications. The medication should also not be used in patients using MAOIs or those who have used these medications within the last 14 days. Lab Values: The patient should be monitored not to develop dependence, addiction, and drug abuse. Nurses should also assess the patient’s pain, respiration, blood pressure, mental status, consciousness, blood pressure, pulse rate, bowel function and urine output, constipation, and symptoms of hypotension.	The patient should be educated on the negative side effects of the medication including dependence, addiction, and drug abuse. The patient should be advised to report any adverse effects such as respiratory depression, constipation, and severe nausea and vomiting to their primary care providers. Advise the patient not to stop using this drug at once as this may cause withdrawal symptoms. Any withdrawal symptoms should be reported to a healthcare provider. When used for a prolonged time, the medication may stop working, hence the need to inform the care provider to change the drug or increase the dosage. The patient should also be advised to change her sitting and lying position frequently to prevent hypotension.  Lastly, teach the patient the importance of dietary fiber, drinking adequate water, and exercise to prevent constipation.
Generic name: Pyridostigmine Brand name: Mestinon Classification: Cholinesterase inhibitor Mode of action: Works by inhibiting the acetylcholinesterase (AChE) enzymes by breaking down the neurotrasmiter acetylcholine (ACh), thereby increasing the bioavailability of ACh and enhancing the transmission of nerve impulses at the neuromuscular junctions.	To treat neuromuscular disease by improving transmission of nerve impulses and increasing muscle strength.	Side effects: Common side effects of this medication include diarrhea, vomiting, blurred vision, watery eyes, pale skin, and stomach upsets. Contraindications: The drug is contraindicated in patients with asthma, cardiac arrhythmias, urinary tract obstruction, and GI obstruction. Lab values: No special lab values to monitor. However, one should assess for breathing, worsening muscle weakness, and excessive sweating.	The patient should be educated to swallow the whole tablet to improve its effectiveness. The patient should continue using the medication even when they feel well to gain maximum befits. Overdose can cause severe illness and muscle weakness. These symptoms should be reported immediately to a healthcare provider for appropriate action.

 

VIII. Nursing Care Plan – Provide any three nursing diagnosis.

Nursing Diagnosis (What’s your patient’s most acute problem?	Objectives / Goals SMART criteria (Relate to your diagnosis)	Interventions (Minimum three, start with non-pharmacological care)	Rationale (Evidenced Based reasons for your interventions)	Evaluation (How do you know your interventions worked?)
Risk for falls or injury related to decreased muscle strength, limited range of motion, and poor balance	The patient will display reduced falls by being able to ambulate, transfer, move in bed, and maintain balance.	1      Assess for factors that contribute to impaired mobility, risk for falls, and address them accordingly 2      Provide non-slip mats and rugs on the floor 3      Assist the patient to practice transfer by implementing strategies that are individualized to the patient’s needs.	Different factors such as stroke, dementia, cerebral palsy, malnutrition, fractures, spinal cord injury, and arthritis may cause impaired mobility. This assessment is critical to determine what conditions need to be treated simultaneously while assisting healthcare providers determine the evidence-based treatment methods (Wayne, 2023). Wet floors can increase the risk for falls and injury. The mats enhance the patient’s stability and reduce risk of slipping (Wagner, 2023). This is critical in maximizing the patient’s mobility	Reduction in falls and injury Improved muscle strength Ability to ambulate, transfer, and move in bed Ability to participate in activities of daily living
Skin breakdown related to inability to ambulate, transfer, or move in bed	The patient will be able to participate in activities of daily living within 2 weeks	Reposition the patient frequently Use devices such as heel off-loading devices and anti-embolic stocking Encourage early mobilization and performance of daily activities (Wayne, 2023).	This is critical in reducing burdening pressure and minimizing skin breakdown These devices help reduce the risk for skin breakdown. Early mobilization reduces skin breakdown and risk for complications	A reduction is skin breakdown and ability to ambulate
Risk for infection and pain	The patient will verbalize a reduction in pain and absence of infections	Provide medication for pain and infections Allow rest periods and relaxation techniques between exercise Reposition the patient frequently and allow the use of assistive devices such as walkers	Medications helps reduce pain and prevent infections on the affected site Rest periods and relaxation allow time to recover and conserve energy. They also help reduce pain. Repositioning the patient reduces excessive pressure on specific pints and reduce skin breakdown.	Reduction in pain and risk for infection Ability to participate in activities of daily living

1. Assessment Tools

Please provide the specific score for each of the following assessment tools and briefly state the significance of the score.

• Braden Score: This scale is used to evaluate the patient’s risk for developing pressure ulcers. The scale is based on 6 items that encompass sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each category is rates based on a scale of 1-4 except that of friction and shear which is scored on a 1-3 scale. The highest score of 23 indicate no risk while the lowest possible score of 6 represent the severest risk for developing pressure ulcers.

Based on Braden scale, the patient has a score of 18 indicating mild risk for developing pressure ulcers.

• Katz ADL Assessment: This scale is critical in assessing basic activities of daily living. The scale analyzes the levels of dependence (Scale 0 point) and independence (scale 1 point) in six daily activities that include bathing, dressing, toileting, transferring, continence, and feeding (Wallace, 2007). A score of 6 indicate fully functional, 4 moderate impairment, and below 2 severe functional impairment (Wayne, 2023). Based on the functional level of the patient, his Katz ADL score is 4 indicating moderate level of impairment.
• Hendrich II Fall Risk: This scale is used to evaluate patients’ risk for falls. The scale explores some of the risk factors that result to falls such as dizziness, altered elimination, depression, confusion, ability to move in a single move among others. A score of 5 or greater indicates high risk for fall (Hendrich, 2012).

• Mini Cog (optional): Unable to assess since dementia cannot be assessed at its early stages.

Note: If not able to assess, please write “unable to assess” and provide an explanation

References

Braden, B. & Bergstrom, N. (1998). Braden scale for predicting pressure sore risk. Assessed on 28^th July 2023 from             https://www.in.gov/health/files/Braden_Scale.pdf

Hendrich, A. (2012). Fall risk assessment for older adults: The Hendrich II Fall risk model. Accessed on 28^th July 2023 form             http://www.wsha.org/wp-content/uploads/Hendrich-II-Fall-Risk.pdf

Wagner, M. (2023). Impaired physical mobility nursing diagnosis and care. https://www.nursetogether.com/impaired-physical- mobility-nursing-diagnosis-care-            plan/#:~:text=Nursing%20Assessment%20for%20Impaired%20Physical,that%20can%20prevent%20purposeful%20movemen    t.

Wallace, M. (2007). Katz index of independence in activities of daily living (ADL). Assessed on 28^th July 2023 from             https://www.alz.org/careplanning/downloads/katz-adl.pdf

Wayne, G. (2023). Physical mobility and immobility care plan and management. https://nurseslabs.com/impaired-physical-mobility