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.
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 a history 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.
Refer patient to a physical therapist to help rehabilitate musculoskeletal deficits.- Demonstrate the standing procedure and note date. Have patient and family members return standing procedure demonstration and note date. This ensures continuity of care and use of proper technique.
Suggested NIC Interventions
Body Mechanics Promotion; Exercise Therapy: Balance; Exercise Therapy: Muscle Control; Positioning; Self-Care Assistance |