Perform ROM exercises to joints, unless contraindicated, at least once every shift. Progress from passive to active, as tolerated. This prevents joint contractures and muscular atrophy.- Place joints in functional position. Maintain joints in a functional position and prevent musculoskeletal deformities.
- Identify the level of functioning using a functional mobility scale (see “Assessment”). Communicate patient's skill level to all staff members to provide continuity and preserve identified level of independence.
Encourage independence by helping patient use assistive devices. This increases muscle tone and patient's self-esteem.- Monitor and record daily any evidence of immobility complications (such as contractures, venous stasis, thrombus, pneumonia, and urinary tract infection). Patients with histories of neuromuscular disorders or dysfunction may be more prone to developing complications.
Instruct patient to call before attempting to stand without assistance. Ensure patient safety from falls.- Carry out a medical regimen to manage or prevent complications; for example, administer prophylactic heparin as ordered for venous thrombosis. This promotes patient's health and well-being.
- Use a transfer belt if necessary to support patient and prevent staff injury.
- Use assistive devices as necessary to support patient and prevent staff injury.
Refer patient to a physical therapist for development of sitting regimen to help rehabilitate musculoskeletal deficits.- Demonstrate the sitting regimen and note date. Have patient and family members return sitting regimen demonstration and note date. This ensures continuity of care and use of proper technique.
Suggested NIC Interventions