Nursing Care Plan Impaired Transfer Ability
Nursing Care Plan Impaired Transfer Ability Definition:At risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities.Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment.Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment. Nursing Care pPlan Impaired transfer ability
- Altered LOC
- Prescribed immobilization
- Mechanical immobilization
- Severe pain
- Cardiac function
- Respiratory function
- Risk management
- Elimination; nutrition
- Tissue integrity
- Fluid and electrolytes
Expected Outcomes The Patient Will
- Have no evidence of altered mental, sensory, or motor ability.
- Have no evidence of thrombus formation or venous stasis.
- Have no evidence of decreased chest movement, cough stimulus,depth of ventilation, pooling of secretions, or signs of infection.
- Maintain normal bowel elimination patterns.
- Maintain adequate dietary intake, hydration, and weight.
- Have no evidence of urine retention, infection, or renal calculi.
- Maintain muscle strength and tone and joint ROM.
- Have no evidence of contractures or skin breakdown.
- Maintain normal neurologic, cardiovascular, respiratory, GI, nutri-tional, genitourinary, musculoskeletal, and integumentary function-ing during period of inactivity.
Suggested Noc Outcomes
Coordinated Movement; Endurance; Immobility Consequences: Phys-iological; Immobility Consequences: Psychocognitive; Mobility; Risk Control
Interventions And Rationales
Determine: Inspect skin every shift and follow facility policy for pre-vention of pressure ulcers to prevent or mitigate skin breakdown.Administer anticoagulant therapy, if ordered; monitor for signs and symptoms of bleeding. Anticoagulant therapy may cause hemorrhage.Monitor vital signs every 4 hr: Monitor breath sounds and respi-ratory rate, rhythm, and depth to rule out respiratory complications.Monitor arterial blood gas levels or pulse oximetry to assess oxygenation, ventilation, and metabolic status.Monitor urine characteristics and patient’s subjective complaint typical of UTIs, such as burning, frequency, and urgency. Obtain urine cultures, as ordered. These measures aid early detection of UTI.115 Identify functional level to provide baseline for future assessment,and encourage appropriate participation in care to prevent complica-tions of immobility and increase patient’s feelings of self-esteem.Perform: Avoid positions that put prolonged pressure on body parts and compress blood vessels; reposition patient at least every 2 hr within prescribed limits. These measures enhance circulation and help prevent tissue or skin breakdown.Use pressure-reducing or pressure-equalizing equipment, as indicated or ordered (ﬂotation pad, air pressure mattress, sheepskin pads, or special bed). This helps prevent skin breakdown by reliev-ing pressure.Apply antiembolism stockings; remove for 1 hr every 8 hr. Stock-ings promote venous return to heart, prevent venous stasis, and decrease or prevent swelling of lower extremities.Suction airway, as needed and ordered, to clear airway and stimu-late cough reﬂex. Note secretion characteristics.Provide small, frequent meals of favorite foods to increase dietary intake. Increase ﬁber content to enhance bowel elimination. Increase protein and vitamin C to promote wound healing; limit calcium to reduce risk of renal and bladder calculi.Perform active or passive ROM exercises at least once per shift.Teach and monitor appropriate isotonic and isometric exercises.These measures prevent joint contractures, muscle atrophy, and other complications of prolonged inactivity.Provide or help with daily hygiene; keep skin dry and lubricate to prevent cracking and possible infection.Inform: Teach and monitor deep breathing, coughing, and use of incentive spirometer to help clear airways, expand lungs, and prevent respiratory complications. Maintain regimen every 2 hr.Instruct patient to avoid straining during bowel movements that may be hazardous to patients with cardiovascular disorders and increased intracranial pressure. Teach to administer stool softeners,suppositories, or laxatives, as ordered, and monitor effectiveness.Attend: Encourage ﬂuid intake of 21⁄2–31⁄2 qt (2.5–3.5 L) daily,unless contraindicated, to maintain urine output and aid bowel elim-ination. Encourage patient and family to verbalize frustrations to help patient and family cope with treatment.
Suggested Nic Interventions
Activity Therapy; Body Mechanics Promotion; Cognitive Stimulation; Energy Management; Exercise Promotion; Exercise Therapy: Ambulation; Fluid Management; Nutrition Management
Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized elderly. The Canadian Nurse, 101(6), 16–20.