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Impaired Physical Mobility

Impaired Physical Mobility

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Amputation
(_) Cardiovascular
(_) External devices
(_) Impaired balance
(_) Limited ROM
(_) Musculoskeletal impairment
(_) Neuromuscular impairment
(_) Pain
(_) Surgical procedure
(_) Trauma
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Inability to move purposefully within the environment, including bed mobility, transfers, and ambulation.
Minor:
(
May be present)
(_) Range of motion limitations.
(_) Limited muscle strength or control.
(_) Impaired coordination.

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
  The patient will:

(_) Maintain or increase strength and endurance of upper/lower limbs A.E.B.:

 

(_) Will not develop complications of immobility.

(_) Demonstrate use of adaptive device(s) to increase mobility.
Device:

 

(_) Other:

 

  (_) Assess symmetry, strength, and degree of mobility.

(_) Passive/active ROM exercises as ordered by physician q_____ to:__________(body part).

(_) Position in proper alignment and resposition q____ hrs.

(_) Encourage isometric exercises when indicated.

(_) Up in chair _____ minutes q____.

(_) Check/teach proper use/function of adaptive equipment.

(_) Provide progressive mobilization.

(_) Referral:

  • PT
  • OT
  • other:

 

(_) Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature