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