Perform ROM exercises to the joints of affected limbs, unless contraindicated, at least once every 8 hours. Progress from passive to active ROM as tolerated to prevent joint contractures and muscle atrophy.- Identify patient's level of independence using the functional mobility scale. Report the findings to the staff to provide continuity and preserve or improve the documented level of independence.
Monitor and record daily evidence of complications related to altered mobility or decreased ability to perform wheelchair transfer (contractures, venous stasis, skin breakdown, thrombus formation, depression, altered health maintenance, or self-care deficit). Patients with neuromuscular dysfunction are at risk for complications.- Teach patient wheelchair transfer techniques, such as performing a standing or sitting transfer, to maintain muscle tone, prevent complications of immobility, and promote independence. Adapt teaching to the limits imposed by patient's condition to prevent injury.
Refer patient to a physical therapist for the development of a wheelchair mobility program to assist with rehabilitation of musculoskeletal deficits.- Encourage patient to attend physical therapy. Request a written copy of wheelchair transfer instructions to use as a reference to maintain continuity of care and foster safety.
Assess patient's skin upon return to bed and request a wheelchair cushion if necessary to maintain skin integrity.- As part of your teaching plan, demonstrate transfer techniques to family members and note the date. Have them perform a return demonstration to ensure the use of proper technique and to promote continuity of care.
- Identify resources (stroke program, sports association for the disabled, National Multiple Sclerosis Society) to promote patient's reintegration into the community.
Suggested NIC Interventions
Body Mechanics Promotion; Energy Management; Exercise Promotion: Strength Training; Exercise Therapy: Balance; Fall Prevention; Self-Care Assistance: Transfer |