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.- Turn and position patient every 2 hours. Establish a turning schedule for dependent patients; post at the bedside and monitor frequency of turning. This prevents skin breakdown by relieving pressure.
- Place joints in functional position, use trochanter roll along the thigh, abduct the thighs, use high-top sneakers, and put a small pillow under patient's head. These measures 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 in mobility by helping patient to use a trapeze and side rails, to use the unaffected leg to move the affected leg, and to perform such self-care activities as combing hair, feeding, and dressing. This increases muscle tone and patient's self-esteem.
- Place items within reach of the unaffected arm if patient has one-sided weakness or paralysis to promote patient's independence.
- Monitor and record daily any evidence of immobility complications (such as contractures, venous stasis, thrombus, pneumonia, and urinary tract infection). Patients with a history of neuromuscular disorders or dysfunction may be more prone to developing complications.
- 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.
- 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. Use a transfer belt if necessary to support patient and prevent staff injury.
Refer patient to a physical therapist for development of mobility regimen to help rehabilitate musculoskeletal deficits. - Encourage attendance at physical therapy sessions and support activities on the unit by using the same equipment and technique. Request written mobility plans and use as reference. All members of the health care team should reinforce learned skills in the same manner.
- Instruct patient and family members in ROM exercises, transfers, skin inspection, and mobility regimen to help prepare patient for discharge.
- Demonstrate the mobility regimen and note date. Have patient and family members return mobility regimen demonstration and note date. This ensures continuity of care and use of proper technique.
- Assist in identifying resources to carry out the mobility regimen, such as the American Heart Association and the National Multiple Sclerosis Society. These resources help provide a comprehensive approach to rehabilitation.
Suggested NIC Interventions
Activity Therapy; Energy Management; Exercise Promotion: Strength Training; Exercise Therapy: Joint Mobility; Exercise Therapy: Muscle Control; Positioning: Wheelchair; Surveillance: Safety |