Perform ROM exercises for joints of affected limbs unless contraindicated at least once per shift. Progress from passive to active ROM as tolerated to prevent joint contractures and muscle atrophy.
Make sure patient maintains anatomically correct and functional body positioning. Encourage repositioning every 2 hours when patient is in bed. Establish a turning schedule for dependent patients. Proper positioning relieves pressure, thereby preventing skin breakdown and fluid accumulation in dependent extremities.- Identify and record patient's level of independence using the functional mobility scale. Communicate the findings to the staff to provide continuity and preserve documented level of independence.
- Implement a preambulation program (e.g., turning in bed, sitting on the side of the bed, sitting up in a chair) to increase independence and patient's self-esteem.
Monitor and record daily evidence of complications related to altered walking, such as contractures, venous stasis, skin breakdown, or thrombus formation. Patient with a history of neuromuscular dysfunction is at risk for complications.- Follow the prescribed medical regimen to manage or prevent complications (e.g., administration of prophylactic heparin for venous thrombosis) to promote patient's health and well-being.
- Provide progressive ambulation up to the limits imposed by patient's condition to maintain muscle tone and prevent complications associated with immobility.
Refer patient to a physical therapist for development of a program to promote walking to assist with rehabilitation of musculoskeletal deficits.- Encourage attendance at physical therapy sessions and reinforce prescribed activities by using the same equipment, devices, and techniques used in therapy sessions. Request a written copy of patient's ambulation program to use as a reference. These measures maintain continuity and help ensure patient's safety.
- Instruct patient and family members in ambulation techniques and measures to prevent complications to help prepare patient and family for discharge.
- Demonstrate ambulation regimen and note the date. Have patient and family members perform a return demonstration to ensure continuity of care and use of proper technique.
- Assist in identifying resources, such as a community stroke program, sports associations for the disabled, or the National Multiple Sclerosis Society, to promote patient's reintegration into the community.
Suggested NIC Interventions
Energy Management; Exercise Promotion: Strength Training; Exercise Therapy: Ambulation; Self-Care Assistance |