Nursing diagnosis – IMPAIRED WHEELCHAIR MOBILITY

IMPAIRED  WHEELCHAIR  MOBILITY

DEFINITION

Limitation of independent operation of wheelchair within environment

DEFINING CHARACTERISTICS

• Impaired ability to operate a manual or power wheelchair on curbs,

even surfaces, uneven surfaces, and/or an incline or a decline

RELATED FACTORS

• Cognitive impairment

• Environmental constraints

• Deconditioning

• Impaired vision

• Deficient knowledge

• Limited endurance

• Depressed mood

• Musculoskeletal impairment

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Pharmacological function

• Neurocognition

EXPECTED OUTCOMES

The patient will

• Have no complications associated with impaired wheelchair mobil-

ity, such as skin breakdown, contractures, venous stasis, thrombus
formation, depression, alteration in health maintenance, and falls.

• Maintain or improve muscle strength and joint ROM.

• Achieve the highest level of independence and safety possible with

regard to wheelchair use.

• Express feelings regarding alteration in ability to use wheelchair.

• Participate in social and occupational activities to the greatest

extent possible.

• Demonstrate understanding of techniques to improve wheelchair

mobility.

SUGGESTED NOC OUTCOMES

Ambulation: Wheelchair; Balance; Mobility Level; Muscle Function

INTERVENTIONS AND RATIONALES

Determine:  Assess wheelchair status: Seat is wide and deep enough

to support thighs, low enough for feet to touch the floor, yet high

enough to allow easy transfer from bed to chair; the back is tall

enough to support upper body; brakes on wheels lock; and seat belt

is present (may attach at waist, hips, or chest). Assessment ensures

chair meets patient’s physical needs (identifies need for modification),

promotes comfort, and prevents injuries (e.g., falls).

Assess patient’s level of strength in arms, and if chair is easy for

patient to operate when weak. This determines the need for a

motorized wheelchair to help maintain mobility and independence.

Identify patient’s level of independence using the functional mobil-

ity scale. Communicate findings to staff to promote continuity of

care and preserve the documented level of independence.

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Monitor and record daily evidence of complications related to

impaired wheelchair mobility. Patients with neuromuscular dysfunc-

tion are at risk for complications.

Assess patient’s skin on return to bed and request a wheelchair

cushion, if necessary, to maintain skin integrity.

Perform:  Perform ROM exercises for affected joints, unless

contraindicated, at least once per shift. Progress from passive to

active ROM as tolerated. This prevents joint contractures and mus-

cle atrophy.

Inform:  Explain to patient location of vulnerable pressure points and

instruct to shift and reposition weight to prevent skin breakdown.

Ensure patient maintains anatomically correct and functional body

positioning to promote comfort.

Demonstrate techniques to promote wheelchair mobility to the

patient and family members and note the date; have them perform a

return demonstration to ensure continuity of care and use of proper

technique.

Attend:  Encourage patient to operate her wheelchair independently

to the limits imposed by her condition to maintain muscle tone,

prevent complications of immobility, and promote independence in

self-care and health maintenance skills.

Encourage attendance at physical therapy sessions and reinforce

prescribed activities on the unit by using equipment, devices, and

techniques used in the therapy session. To maintain continuity of

care and promote patient safety.

Manage:  Refer patient to a physical therapist to enhance wheelchair

mobility and rehabilitation of musculoskeletal deficits.

Help patient identify resources for maintaining highest level of

mobility (e.g., community stroke program, sports associations for

people with disabilities, and the National Multiple Sclerosis Society)

to promote reintegration into the community.

SUGGESTED NIC INTERVENTIONS

Exercise Promotion: Strength Training; Exercise Therapy: Balance;

Exercise Therapy: Muscle Control; Positioning: Wheelchair

Reference

Gavin-Dreschnack, D., et al. (2005, April–June). Wheelchair-related falls: Cur-

rent evidence and directions for improved quality care. Journal of Nursing
Care Quality, 20(2), 119–127.

Nursing diagnosis – IMPAIRED PHYSICAL MOBILITY

IMPAIRED  PHYSICAL  MOBILITY

DEFINITION

Limitation in independent, purposeful physical movement of the

body or of one or more extremities

DEFINING CHARACTERISTICS

• Gait changes, postural instability; difficulty turning

• Limited ROM; ability to perform fine and gross motor skills

• Movement-induced tremor, uncoordinated or jerky movements

• Slowed and/or uncoordinated movements; reaction time.

• Substitution of other behaviors for impaired mobility (for instance,

increased attention to other’s activity and controlling behavior)

RELATED FACTORS

• Activity intolerance

• Decreased endurance; muscle

• Altered cellular metabolism

control, mass or strength

• Body mass index above

• Depressive mood state

75th percentile

• Deficient knowledge about

• Cognitive impairment

value of exercise

• Contractures

• Developmental delay

• Cultural beliefs regarding

• Discomfort

age-appropriate activity

• Disuse

• Deconditioning

• Joint stiffness

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

EXPECTED OUTCOMES

The patient will

• Maintain muscle strength and joint ROM.

• Be free from complications (e.g., contractures, venous stasis,

thrombus formation, skin breakdown, and hypostatic pneumonia).

• Achieve the highest level of mobility (will transfer independently,

will be wheelchair-independent, or will ambulate with assistive
devices such as walker, cane, and braces).

• Carry out mobility regimen.

• Use resources to help maintain level of functioning.

SUGGESTED NOC OUTCOMES

Ambulation; Ambulation: Wheelchair; Joint Movement: Hip; Joint

Movement: Shoulder; Mobility; Transfer Performance

INTERVENTIONS AND RATIONALES

Determine:  Identify level of functioning using a functional mobility

scale. Communicate patient’s skill level to all staff members to pro-

vide continuity and preserve identified level of independence.

Monitor and record daily any evidence of immobility

complications as they may be more prone to develop complications.

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Perform:  Perform ROM exercises to joints, unless contraindicated, at

least once every shift to prevent joint contractures and muscular

atrophy. Turn and reposition patient every 2 hr. Establish a turning

schedule and post at bedside. Monitor frequency of turning to pre-

vent skin breakdown by relieving pressure. Place joints in functional

position. Use trochanter roll along the thigh, abduct thighs, use

high-top sneakers, and pull a small pillow under patient’s head to

maintain joints in a functional position and prevent musculoskeletal

deformities.

Place items within reach of the unaffected arm if patient has one-

sided weakness or paralysis to promote patient’s independence.

Carry out medical regimen to manage or prevent complications

(e.g., administer prophylactic heparin for venous thrombosis). This

promotes patient’s health and well-being.

Provide progressive mobilization to the limits of patient’s

condition (bed mobility to chair mobility to ambulation) to maintain

muscle tone and prevent complications of immobility.

Inform:  Instruct patient and family members in ROM exercises,

transfers, skin inspection, and mobility regimen to help prepare for

discharge and promote continuity of care. Request return

demonstration to ensure use of proper technique.

Attend:  Help patient use a trapeze and side rails to encourage inde-

pendence in mobility. Instruct him to perform self-care activities to

increase muscle tone.

Encourage physical therapy sessions and support activities on the

unit by using the same equipment and technique. Request written

mobility plans for reference. Ensure all members of the healthcare

team are reinforcing learned skills in the same manner.

Manage:  Refer patient to a physical therapist for development of

mobility regimen to help rehabilitate musculoskeletal deficits.

Assist patient in identifying resources such as American Heart

Association to provide a comprehensive approach to rehabilitation.

SUGGESTED NIC INTERVENTIONS

Exercise Promotion: Strength Training; Exercise Therapy: Joint

Mobility; Exercise Therapy: Muscle Control; Positioning: Wheelchair

Reference

Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized

elderly. The Canadian Nurse, 101(6), 16–20.

Nursing diagnosis – IMPAIRED BED MOBILITY

IMPAIRED  BED  MOBILITY

DEFINITION

Limitation of independent movement from one bed position to another

DEFINING CHARACTERISTICS

Impaired ability to perform the following actions while in bed:

• Move from supine to long sitting or long sitting to supine

• Move from supine to prone or prone to supine

• Move from supine to sitting or sitting to supine

• “Scoot” or reposition body

• Turn from side to side

RELATED FACTORS

• Cognitive impairment

• Musculoskeletal and/or

• Deconditioning

neuromuscular impairment

• Deficient knowledge

• Obesity

• Environmental constraints

• Pain

• Insufficient muscle strength

• Sedating medications

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Pharmacological function

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Have no complications associated with impaired bed mobility,

such as altered skin integrity, contractures, venous stasis, thrombus
formation, depression, altered health maintenance, and falls.

• Maintain or improve muscle strength and joint ROM.

• Achieve the highest level of bed mobility possible (independence,

independence with device, verbalization of needs for assistance with
bed mobility, requires assistance of one person or two people).

• Demonstrate ability to use equipment or devices to assist with

moving about in bed safely.

• Adapt to alteration in ability to move about in bed.

• Participate in social, physical, and occupational activities to the

extent possible.

SUGGESTED NOC OUTCOMES

Body Positioning: Self-Initiated; Cognition; Immobility

Consequences: Physiological; Immobility Consequences: Psychocogni-

tive; Joint Movement, Mobility; Neurological Status: Consciousness

INTERVENTIONS AND RATIONALES

Determine:  Identify patient’s level of independence using functional

mobility scale and document findings to provide continuity of care.

Monitor and record daily evidence of complications related to

impaired bed mobility (contractures, venous stasis, skin breakdown,

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thrombus formation, depression, altered health maintenance or self-

care skills, falls). Assess patient’s skin every 2 hr to maintain skin

integrity.

Perform:  Perform ROM exercises to affected joints, unless

contraindicated, at least once per shift. Progress from passive to

active ROM, as tolerated, to prevent joint contractures and muscle

atrophy.

Assist patient in maintaining anatomically correct and functional

body positioning to relieve pressure, thereby preventing skin break-

down and fluid accumulation in dependent extremities. Encourage

repositioning every 2 hr while in bed.

Establish a turning schedule for immobile patient. Encourage pro-

gressive mobility within patient’s limits to maintain muscle tone,

prevent complications, and promote self-care.

If you are uncertain about your ability to move the patient,

request help from colleagues to maintain safety.

Inform:  Instruct patient and family members in techniques to

improve bed mobility and ways to prevent complications to help

prepare the patient and family members for discharge.

Demonstrate patient’s bed mobility regimen and note the date.

Have patient and family members perform a return demonstration

to ensure continuity of care and use of proper technique.

Attend:  Encourage patient to participate in physical and

occupational therapy sessions. Incorporate equipment, devices, and

techniques used by therapists into your care. Request written

instructions from the patient’s therapists to use as a reference to

help ensure continuity of care and reinforce learned skills.

Manage:  Refer patient to a physical therapist to continue improve-

ment in bed mobility and rehabilitate musculoskeletal deficits; and

an occupational therapist to continue to maximize self-care skills.

Assist patient in identifying and contacting resources for social

and spiritual support to promote the patient’s reintegration into the

community and help him maintain psychosocial health.

SUGGESTED NIC INTERVENTIONS

Bed Rest Care; Body Mechanics Promotion; Exercise Promotion:

Strength Training; Exercise Therapy: Joint Mobility; Exercise Ther-

apy: Muscle Control; Positioning

Reference

Lyder, C. H. (2006, August). Assessing risk and preventing pressure ulcers in

patients with cancer. Seminars in Oncology Nursing, 22(3), 178–184.