M
Risk for disturbed Maternal/Fetal Dyad
At risk for disruption of the symbiotic maternal/fetal dyad as a result of comorbid or pregnancy-related conditions
Risk Factors
Complications of pregnancy (e.g., premature rupture of membranes, placenta previa or abruption, late prenatal care, multiple gestation, malnutrition); compromised O2 transport (e.g., anemia, cardiac disease, asthma, hypertension, seizures, premature labor, hemorrhage); impaired glucose metabolism (e.g., diabetes, steroid use); physical abuse; substance abuse (e.g., tobacco, alcohol, drugs); treatment-related side effects (e.g., medications, surgery, chemotherapy)
Client Outcomes
Client Will (Specify Time Frame)
• Cope with discomforts of high-risk pregnancy until delivery of baby
• Adhere to prescribed regimens to maintain homeostasis during pregnancy
Nursing Interventions
• Standardize internal and external transport forms using SBAR format (situation, background, assessment, recommendation) to provide safe and efficient transport of a high-risk pregnant client.
Arrange for psychotherapeutic support when woman expresses intense fear related to high-risk pregnancy and fetal outcomes.
• Screen all antepartum clients for depression using a tool that evaluates the biopsychosocial-spiritual dimensions in a culturally sensitive way.
• Offer flexible visiting hours; private space for families; and nursing support for management of family stressors, including music and recreation therapy, when a woman is hospitalized with a high-risk pregnancy.
• Focus on the abilities of a woman with disabilities by encouraging her to identify her support system, resources, and needs for modification of her environment.
• Recognize patterns of physical abuse in all pregnant and postpartum women, regardless of age, race, and socioeconomic status.
• Perform accurate blood pressure readings at each client’s clinic encounter.
• Provide educational materials and support for personal autonomy about genetic counseling and testing options prior to pregnancy, that is, preimplantation genetic testing, or during pregnancy, that is, fetal nuchal translucency ultrasound, quadruple screen, cystic fibrosis.
• Identify adherence barriers and assist with meal selections to maintain optimal and safe pregnancy weight gain (25 to 35 pounds; 15 to 25 if overweight).
• Use an analogy to explain the pathophysiology of gestational diabetes to teach a pregnant woman about management and treatment.
• Utilize the 5As (tobacco cessation interventions) to treat tobacco use and dependence in pregnant women.
• When questioning at-risk clients regarding recreational drug use, ask if they have used substances such as marijuana or cocaine within the last month, instead of questioning if have used within the last few days.
Refer clients who self-report drug abuse or have positive toxicology screens to a comprehensive addiction program designed for the pregnant woman.
• Encourage pregnant women to utilize electronic resources, such as Text4Baby or whattoexpect.com, to track pregnancy progress and provide education and motivation to make healthy lifestyle choices (abstinence from poor nutrition, smoking, alcohol, etc.).
Impaired Memory
Inability to remember or recall bits of information or behavioral skills; impaired memory may be attributed to pathophysiological or situational causes that are either temporary or permanent
Defining Characteristics
Experience of forgetting; forgets to perform a behavior at a scheduled time; inability to determine if a behavior was performed; inability to learn new information; inability to learn new skills; inability to perform a previously learned skill; inability to recall events; inability to recall factual information; inability to retain new information; inability to retain new skills
Related Factors (r/t)
Anemia; decreased cardiac output; excessive environmental disturbances; fluid and electrolyte imbalance; hypoxia; neurological disturbances
Client Outcomes
Client Will (Specify Time Frame)
Nursing Interventions
• Assess overall cognitive function and memory. The emphasis of the assessment is everyday memory, the day-to-day operations of memory in real-world ordinary situations. Use an assessment tool such as the Mini-Mental State Examination (MMSE).
• Determine whether onset of memory loss is gradual or sudden. If memory loss is sudden, refer the client to a physician or neuropsychologist for evaluation.
• Determine amount and pattern of alcohol intake.
• Note the client’s current medications and intake of any mind-altering substances such as benzodiazepines, ecstasy, marijuana, cocaine, or glucocorticoids.
• Note the client’s current level of stress. Ask if there has been a recent traumatic event.
• If stress was associated with memory loss, refer to a stress reduction clinic. If not available, suggest that the client meditate, receive massages, and participate in moderate physical activity, all of which may promote stress reduction and reduce anxiety and depression.
• Encourage the client to develop an aerobic exercise program.
• Determine the client’s sleep patterns. If insufficient, refer to care plan for Disturbed Sleep Pattern.
• Determine the client’s blood sugar levels. If they are elevated, refer to physician for treatment and encourage healthy diet and exercise.
• If signs of depression such as weight loss, insomnia, or sad affect are evident, refer the client for psychotherapy.
Perform a nutritional assessment. If nutritional status is marginal, confer with a dietitian and primary care practitioner to evaluate whether the client needs supplementation with foods or vitamins. Teach the client the need to eat a healthy diet with adequate intake of whole grains, fruits, and vegetables to decrease cerebrovascular infarcts.
• Question the client about cholesterol level. If it is high, refer to physician or dietitian for help in lowering. Encourage the client to eat a healthy diet, avoiding saturated fats and trans fatty acids.
• Suggest clients use cues, including alarm watches, electronic organizers, calendars, lists, or pocket computers, to trigger certain actions at designated times.
• Encourage the client to participate in a multicomponent cognitive rehabilitation program that recommends stress and relaxation training, physical activity, external memory devices, such as a calendar for appointments and reminder lists.
• Help the client set up a medication box that reminds the client to take medication at needed times; assist the client with refilling the box at intervals if necessary.
• If safety is an issue with certain activities (e.g., the client forgets to turn off stove after use or forgets emergency telephone numbers), suggest alternatives such as using a microwave or whistling teakettle for heating water and programming emergency numbers in telephone so that they are readily available.
• Refer the client to a memory clinic (if available), a neuropsychologist, or an occupational therapist.
• For clients with memory impairments associated with dementia, see care plan for Chronic Confusion.
• Assess for signs of depression.
• Evaluate all medications that the client is taking to determine whether they are causing the memory loss, particularly drugs used to treat an overactive bladder.
• Evaluate all herbal and/or nutraceutical products that the individual might be using to improve memory function.
• Recommend that elderly clients maintain a positive attitude and active involvement with the world around them and that they maintain good nutrition.
• Encourage the elderly to believe in themselves and to work to improve their memory.
• Refer the client to a memory class that focuses on helping older adults learn memory strategies
• Help family label items such as the bathroom or sock drawer to increase recall.
• Assess for the influence of cultural beliefs, norms, and values on the family or caregiver’s understanding of impaired memory.
• When assessing memory in Mexican Americans, the MMSE has been tested.
• Inform the client’s family or caregiver of meaning of and reasons for common behavior observed in the client with impaired memory, which can vary depending on race and ethnicity.
• Attempt to validate family members’ feelings regarding the impact of the client’s behavior on family lifestyle.
• The preceding interventions may be adapted for home care use.
• Assess the client’s need for outside assistance with recall of treatment, medications, and willingness/ability of family to provide needed support.
• Identify a checking-in support system (e.g., Lifeline or significant others).
• Keep furniture placement and household patterns consistent.
Client/Family Teaching and Discharge Planning
• When teaching the client, determine what the client knows about memory techniques and then build on that knowledge.
• When teaching a skill to the client, set up a series of practice attempts that will enhance motivation. Begin with simple tasks so that the client can be positively reinforced and progress to more difficult concepts.
• Teach clients to use memory techniques such as concentrating and attending, repeating information, making mental associations, and placing items in strategic places so that they will not be forgotten.
Impaired bed Mobility
Defining Characteristics
Impaired ability to move from supine to sitting; to move from sitting to supine; to move from supine to prone; to move from prone to supine; to move from supine to long sitting; to move from long sitting to supine; to “scoot” or reposition self in bed; to turn from side to side
Related Factors (r/t)
Cognitive impairment; deconditioning; deficient knowledge; environmental constraints (i.e., bed size, bed type, treatment equipment, restraints); insufficient muscle strength; musculoskeletal impairment; neuromuscular impairment; obesity; pain; sedating medications. NOTE: Specify level of independence using a standardized functional scale
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate optimal independence in positioning, exercising, and performing functional activities in bed
• Demonstrate ability to direct others on how to do bed positioning, exercising, and functional activities
Nursing Interventions
• Critically think/set priorities to use the most therapeutic bed positions based on client’s history, risk profile, preventive needs; realize positioning for one condition may negatively affect another.
• Assess client’s risk for aspiration; if present, elevate HOB to 30 degrees and elevate HOB to 90 degrees during oral intake.
• Raise head of bed (HOB) to 30 degrees for clients with acute increased intracranial pressure (ICP) and brain injury. Refer to care plan for Decreased Intracranial Adaptive Capacity.
Consult physician for HOB elevation of clients with acute stroke and monitor their response. Refer to care plan for Decreased Intracranial Adaptive Capacity.
• Raise HOB as close to 45 degrees as possible for critically ill, ventilated clients to prevent pneumonia (this height may place clients at higher risk for pressure ulcers).
• Assist client to sit as upright as possible during meals/ingestion of pills if dysphagic. Refer to care plan for Impaired Swallowing.
• Periodically sit client as upright as tolerated in bed and dangle client, if vital signs/oxygen saturation levels remain stable.
• Maintain HOB at lowest elevation that is medically possible to prevent shear-related injury; check sacrum often.
• Trial prone positioning for clients with acute respiratory distress syndrome (ARDS), acute lung injury (ALI), and amputation and monitor their tolerance/response.
• Assess client’s risk for falls using a valid tool, establish individualized fall prevention strategies, and perform postfall assessment to further refine fall prevention interventions.
• Lock bed brakes, use low-rise beds at lowest position with floor mats next to them, avoid use of side rails, and apply personal exit alarms on confused clients.
Avoid use of bedrails and restraints unless ordered by physician.
• Place call light, bedside table, and telephone within reach of clients.
• Use a formalized screening tool to identify persons at high risk for thromboembolism (DVT).
Implement thromboembolism prophylaxis/treatment as ordered (e.g., anticoagulants, antiembolic stockings, elastic leg wraps, sequential compression devices, feet/ankle exercises, and hydration). Refer to care plan for Ineffective peripheral Tissue Perfusion.
• Use a formal tool to assess for risk of pressure ulcers.
• Implement the following interventions to prevent pressure ulcers and complications of immobility:
Position sitting clients with special attention to the individual’s anatomy, postural alignment, distribution of weight, and support of feet; heel protection devices should completely offload (float) the heel.
Turn (logroll) clients at high risk for pressure/shear/friction frequently and regularly.
Use statis/dynamic bed surfaces and assess for “bottoming out” under susceptible bony areas (body sinks into mattress, thus the recommended 1 inch between mattress/bones is absent). Refer to care plan for Risk for impaired Skin Integrity.
Use heel protection devices that completely float or offload heels.
Implement a 2-hour on/off schedule for heel protector boots or high-top tennis shoes with socks underneath on clients with paralyzed feet, and check condition of heels when removed.
Strictly maintain leg abduction in persons with a surgical hip pinning or replacement by placing an abductor splint/pillow between legs.
Use devices such as trapeze, friction-reducing slide sheets, mechanical lateral transfer aids, and ceiling-mounted or floor lifts to move (rather than drag) dependent/obese persons in bed.
Apply elbow pads to comatose/restrained clients and to those who use elbows to prop/scoot up in bed; apply nocturnal elbow splint as ordered if ulnar nerve palsy exists or if painful elbow with paresthesia in ulnar side of fourth/fifth fingers develops.
• Explain importance of exhaling versus holding one’s breath (Valsalva maneuver) and straining during bed activities.
• Reassess pain level, especially before movement/exercising, and accept clients’ pain rating and level they think is appropriate for comfort, then administer analgesics based on pain rating. Refer to Acute Pain or Chronic Pain.
• Use special beds/equipment to move bariatric (very obese) clients, such as mattress overlay, sliding/roller board, trapeze, stirrup, and pulley attached to overhead traction system (holds one leg up during pericare).
• Place bariatric clients in free-standing or ceiling-mounted lifts with padded slings while changing bed linen.
• Place bariatric beds along a corner wall.
• Identify/modify hospital beds with large gaps between bed rail/mattress that create an entrapment hazard. Ensure that mattresses fit the bed; instill gap fillers/rail inserts, then monitor effectiveness.
• Test strength in bilateral grips, arms at elbow flexion and extension, bilateral arm abduction and adduction, bilateral leg or thigh raise (one at a time in bed or chair), and quadriceps and hamstring strength to extend and flex at knee to assess baseline and interval strength gains.
• Perform passive range of motion (ROM) of three repetitions, at least twice a day, to immobile joints.
• Perform ROM slowly/rhythmically. Do not range beyond point of pain. Range only to point of resistance in those with loss of sensation/mentation.
• Range/move a hemiplegic arm with the shoulder slightly externally rotated (hand up).
Emphasize client’s practice of exercises taught by therapists (muscle setting, strengthening, contraction against resistance, and weight lifting).
• Incorporate the following measures to promote normal tone and prevent complications in clients with neurological impairment:
Use a flat head pillow when clients are supine. Use a small pillow behind the head and/or between shoulder blades if neck extension occurs.
Abduct the shoulders of persons with high paraplegia or quadriplegia horizontally to 90 degrees briefly two or three times a day while supine.
Position a hemiplegic shoulder fairly close to the client’s body.
Elevate paralyzed forearm(s) on a pillow when supine and apply Isotoner gloves; elevate edematous legs on a pillow and apply elastic wraps and compression garments as ordered.
• Tilt hemiplegics onto both unaffected/affected sides with the affected shoulder slightly forward (move/lift the affected shoulder, not the forearm/hand).
Apply resting wrist and hand splints. Strictly adhere to on/off orders. Routinely check underlying skin for signs of pressure/poor circulation.
Range weak/paralyzed ankle joints before applying foot splints, boots, or high-top tennis shoes on rotation schedule recommended by the physical therapist; routinely assess underlying skin for signs of pressure.
Recognize that components of normal bed mobility include rolling, bridging, scooting, long sitting, and sitting upright. Activity starts with the client supine, flat in bed, and promotes normal movements that are bilateral, segmental, well timed, and involve set positions such as weight bearing and trunk centering. Refer to physical therapist (PT) for individualized instructions/strategies.
• Assess caregivers’ strength, health history, and cognitive status to predict ability/risk for assisting bed-bound clients at home. Explore alternatives if risk is too high. Refer to care plan for Caregiver Role Strain.
• Assess the client’s stamina and energy level during bed activities/exercises; if limited, spread out activities and allow rest breaks.
Utilize nurse case managers, care coordinators, or social workers to assess support systems and identify need for durable medical equipment, assistive technology, and home health services.
• Encourage use of the client’s bed unless contraindicated. Raise HOB with commercial blocks or grooved-out pieces of wood under legs; set bed against walls in a corner.
• Suggest home modifications and rearranging rooms/furniture to meet sleeping/toileting/living needs on one level.
• Stress psychological/physical benefits of clients being as self-sufficient as possible with bed mobility/care even though it may be time-consuming.
• Offer emotional support and help client identify usual coping responses to help with adjustment and loss issues.
• Discuss support systems available for caregivers to help them cope. Please refer to care plan for Caregiver Role Strain.
In the presence of medical disorders, institute case management for the frail elderly to support continued independent living.
• Refer to the Home Care interventions of the care plan for Impaired physical Mobility.
Client/Family Teaching and Discharge Planning
• Use various sensory modalities to teach client/caregivers correct ROM, exercises, positioning, self-care activities, and use of devices. Readiness and learning styles vary but may be enhanced with visual/auditory/tactile/cognitive stimulus as follows:
Provide visual information such as demonstrations, sketches, instructional videos, written directions/schedules, notes.
Provide auditory information such as verbal instructions, recorded audiotapes, timers, reading aloud written directions, and self-talk during activities.
Use tactile stimulation such as motor task practice/repetition, return demonstrations, note taking, manual guidance, or staff’s-hand-on-client’s-hand technique.
• Schedule time with family/caregivers for education and practice; for nursing as well as physical therapy and occupational therapy. Suggest family come prepared with questions and wear comfortable, safe clothing/shoes.
• Implement safe approaches for caregivers/home care staff and reinforce adequate number of people and handling equipment (friction pads, slide boards, lifts, etc.) during bed mobility, exercise, toileting, and bathing.
• Coordinate bariatric equipment for home use before discharge, including a weight-rated bed, a wheelchair or mobility device (scooter) and lift device; doorways may need to be widened, floors reinforced, and ramps may need to be added for safety.
Impaired physical Mobility
Defining Characteristics
Decreased reaction time; difficulty turning; engages in substitutions for movement (e.g., increased attention to other’s activity, controlling behavior, focus on pre-illness disability/activity); exertional dyspnea; gait changes; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movements
Related Factors (r/t)
Activity intolerance; altered cellular metabolism; anxiety; body mass index above 75th age-appropriate percentile; cognitive impairment; contractures; cultural beliefs regarding age-appropriate activity; deconditioning; decreased endurance; depressive mood state; decreased muscle control; decreased muscle mass; decreased muscle strength; deficient knowledge regarding value of physical activity; developmental delay; discomfort; disuse; joint stiffness; lack of environmental supports (e.g., physical or social); limited cardiovascular endurance; loss of integrity of bone structures; malnutrition; medications; musculoskeletal impairment; neuromuscular impairment; pain; prescribed movement restrictions; reluctance to initiate movement; sedentary lifestyle; sensoriperceptual impairments
Suggested functional level classifications include the following:
Client Outcomes
Client Will (Specify Time Frame)
• Meet mutually defined goals of increased ambulation and exercise that include individual choice, preference and enjoyment in the exercise prescription.
• Verbalize feeling of increased strength and ability to move.
• Verbalize less fear of falling and pain with physical activity.
• Demonstrate use of adaptive equipment (e.g., wheelchairs, walkers, gait belts, weighted walking vests) to increase mobility.
• Increase exercise to 20 minutes per day for those who were previously sedentary (less than 150 minutes per week). NOTE: Light to moderate intensity exercise may be beneficial in deconditioned persons. In very deconditioned individuals exercise bouts of less than 10 minutes are beneficial.
• Increase pedometer step counts by 1000 steps per day every 2 weeks to reach a daily step count of at least 7000 steps per day, with a daily goal for most healthy adults of 10,000 steps per day (approximately 5 miles).
• Perform resistance exercises that involve all major muscle groups (legs, hips, back, chest, abdomen, shoulders, and arms) performed 2 or 3 days per week.
• Perform flexibility exercise (stretching) for each of the major muscle-tendon groups 2 days per week for 10 to 60 seconds to improve joint range of motion; greatest gains occur with daily exercise.
• Engage in neuromotor exercise 20 to 30 minutes per day including motor skills (e.g., balance, agility, coordination, and gait), proprioceptive exercise training, and multifaceted activities (e.g., tai chi and yoga) to improve and maintain physical function and reduce falls in those at risk for falling (older persons).
• Engage in purposeful moderate-intensity cardiorespiratory (aerobic) exercise for 30 to 60 minutes per day on at least 5 days per week for a total of 2 hours and 30 minutes (150 minutes) per week.
Nursing Interventions
NOTE: Adults with disabilities should follow the adult guidelines; however, if not possible these persons should be as physically active as their abilities allow and avoid inactivity. Use “start low and go slow” approach for intensity and duration of physical activity if client highly deconditioned, functionally limited, or has chronic conditions affecting performance of physical tasks. When progressing client’s activities, use an individualized and tailored approach based on client’s tolerance and preferences.
• Screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting; (3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Use a tool such as the Assessment Criteria and Care Plan for Safe Patient Handling and Movement.
• Screen for additional measures of physical function to assess strength of muscle groups, including unassisted leg stand, use of a balance platform, elbow flexion and knee extension strength, grip strength, timed chair stands, and the 6-minute walk.
• Assess the client for cause of impaired mobility. Determine whether cause is physical, psychological, or motivational. Refer to care plans for Risk for Falls, Acute or Chronic Pain, Ineffective Coping, or Hopelessness.
• Use Self-Efficacy for Exercise Scale and the Outcome Expectation for Exercise Scale to determine client’s self-efficacy and outcome expectations toward exercise.
• Monitor and record the client’s ability to tolerate activity and use all four extremities; note pulse rate, blood pressure, dyspnea, and skin color before and after activity. Refer to the care plan for Activity Intolerance.
Before activity, observe for and, if possible, treat pain with massage, heat pack to affected area, or medication. Ensure that the client is not oversedated.
Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan.
• Obtain any assistive devices needed for activity, such as gait belt, weighted vest, walker, cane, crutches, or wheelchair, before the activity begins.
• If the client is immobile, perform passive ROM exercises at least twice a day unless contraindicated; repeat each maneuver three times.
If the client is immobile, consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin with the following exercises:
Active ROM exercises using both upper and lower extremities (e.g., flexing and extending at ankles, knees, hips)
Chin-ups and pull-ups using a trapeze in bed (may be contraindicated in clients with cardiac conditions)
Strengthening exercises such as gluteal or quadriceps sitting exercises
• If client is immobile, consider use of vertical transfer techniques such as a transfer chair or gait belt pending weight-bearing status and client cooperation.
• Help the client achieve mobility and start walking as soon as possible if not contraindicated.
• Use a gait-walking belt when ambulating the client.
Apply any ordered brace before mobilizing the client.
• Initiate a “No Lift” policy where appropriate assistive devices are used for manual lifting.
• Increase independence in ADLs, encouraging self-efficacy and discouraging helplessness as the client gets stronger.
If the client has osteoarthritis or rheumatoid arthritis, ask for a referral to a physical therapist to begin an exercise program that includes aerobic exercise, resistance exercise, and flexibility exercise (stretching).
If client has had a cerebrovascular accident (CVA) with hemiparesis, consider use of constraint-induced movement therapy (CIMT), where the functional extremity is purposely constrained and the client is forced to use the involved extremity.
• If the client has had a CVA, recognize that balance and mobility are likely impaired, and engage client in fall prevention strategies and protect from falling.
• If the client does not feed or groom self, sit side-by-side with the client, put your hand over the client’s hand, support the client’s elbow with your other hand, and help the client feed self; use the same technique to help the client comb hair.
• Assess ability to move using valid and reliable criterion-referenced standards for fitness testing (e.g., Senior Fitness Test) designed for older adults that can predict the level of capacity associated with maintaining physical independence into later years of life (e.g., get up and go test).
• Help the mostly immobile client achieve mobility as soon as possible, depending on physical condition.
• For a client who is mostly immobile, minimize cardiovascular deconditioning by positioning the client in the upright position several times daily.
Refer the client to physical therapy for resistance exercise training as able, involving all major muscle groups (e.g., abdominal crunch, leg press, leg extension, leg curl, and calf press).
• Use the Function-Focused Care (FFC) rehabilitative philosophy of care with older adults in residential nursing facilities to prevent avoidable functional decline. The primary goals of FFC are to alter how direct care workers (DCWs) provide care to residents to maintain and improve time spent in physical activity and improve or maintain function.
• If client is scheduled for an elective surgery that will result in admission into the intensive care unit (ICU) and immobility, or recovery from a joint replacement, for example, initiate a prehabilitation program that includes a warm-up, aerobic activity, strength, flexibility, neuromotor, and functional task work.
Evaluate the client for signs of depression (flat affect, insomnia, anorexia, frequent somatic complaints), anxiety or cognitive impairment (use Mini-Mental State Exam [MMSE]). Refer for treatment and counseling as needed.
• Watch for orthostatic hypotension when mobilizing elderly clients. Have the client dangle at the side of the bed with legs hanging over the edge of the bed, flex and extend feet several times after sitting up, then stand up slowly with someone holding the client. If client becomes lightheaded or dizzy, return him to bed immediately.
• Do not routinely assist with transfers or bathing activities unless necessary.
• Use gestures and nonverbal cues when helping clients move if they are anxious or have difficulty understanding and following verbal instructions.
• Recognize that wheelchairs are not a good mobility device and often serve as a mobility restraint.
• Ensure that chairs fit clients. Chair seat should be 3 inches above the height of the knee. Provide a raised toilet seat if needed.
• If the client is mainly immobile, provide opportunities for socialization and sensory stimulation (e.g., television and visits). Refer to the care plan for Deficient Diversional Activity.
• Recognize that immobility and a lack of social support and sensory input may result in confusion or depression in the elderly. Refer to nursing interventions for Acute Confusion or Hopelessness as appropriate.
• The preceding interventions may be adapted for home care use.
Begin discharge planning as soon as possible with a personal health navigator (e.g., nurse care coordinator or case manager) to assess need for home support systems, assistive devices, and community or home health services.
Assess home environment for factors that create barriers to physical mobility. Refer to occupational therapy services if needed to assist the client in restructuring home environment and daily living patterns.
Refer to home health aide services to support the client and family through changing levels of mobility. Reinforce need to promote independence in mobility as tolerated.
Refer to physical therapy for gait training, strengthening, and balance training. Physical therapists can provide direct interventions as well as assess need for assistive devices (e.g., cane, walker).
• Discuss with client and caregiver the possibility of a service dog to support the more immobile client.
• Assess skin condition at every visit. Establish a skin care program that enhances circulation and maximizes position changes.
• Once the client is able to walk independently, suggest the client enter an exercise program, or walk with a friend.
• Provide support to the client and family/caregivers during long-term impaired mobility. Refer to the care plan for Caregiver Role Strain.
Institute a personal health navigator (e.g., nurse care coordinator or case manager) and transitional care management of frail older adults to support continued independent living.
Client/Family Teaching and Discharge Planning
• Consider using motivational interviewing techniques when working with both children and adult clients to increase their activity.
• Teach the client progressive mobilization (e.g., dangle legs, get out of bed slowly when transferring from the bed to the chair).
• Teach the client relaxation techniques such as deep breathing and stretching to use during activity.
• Teach the client to use assistive devices such as a cane, a walker, gait belt, weighted vest, or crutches or wheelchair to increase mobility.
• Teach family members and caregivers to work with clients actively during self-care activities using a restorative care philosophy for eating, bathing, grooming, dressing, and transferring to restore the client to maximum function and independence.
• Work with the client using self-efficacy interventions using single or multiple methods. Teach client and family members to assess fear of falling and develop strategies to mitigate its effect on mobility progression.
• Work with the client using theory-based interventions (e.g., social cognitive theoretical components such as self-efficacy; transtheoretical model).
Impaired wheelchair Mobility
Defining Characteristics
Impaired ability to operate: manual or powered wheelchair on curbs; manual or powered wheelchair on even surface; manual or power wheelchair on an uneven surface; manual or powered wheelchair on an incline; manual or powered wheelchair on a decline
Related Factors (r/t)
Cognitive impairment; deconditioning; deficient knowledge; depressed mood; environmental constraints (e.g., stairs, inclines, uneven surfaces, unsafe obstacles, distances, lack of assistive devices or person, wheelchair type); impaired vision; insufficient muscle strength; limited endurance; musculoskeletal impairment (e.g., contractures); neuromuscular impairment; obesity; pain
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate independence in operating and moving a wheelchair or other device with wheels
• Demonstrate the ability to direct others in operating and moving a wheelchair or other device
• Demonstrate therapeutic positioning, pressure relief, and safety principles while operating and moving wheelchair or other device equipped with wheels
Nursing Interventions
• Assist client to put on and take off equipment (e.g., braces, orthoses, abdominal binders) in bed.
• Inspect skin where orthoses, braces, and other equipment rested, once they are removed.
Obtain referrals for physical and occupational therapy, or wheelchair seating clinic.
• Recognize that use of support surfaces (on chairs and beds ) redistributes pressure and should be used an adjunct to reduce the risk of developing pressure ulcers in addition to repositioning the client on a regular schedule.
• Intervene to maintain continence or use absorbent diapers to help prevent skin breakdown due to wet, macerated skin. Some wheelchair cushions have moisture-wicking characteristics
• Maintain nutrition and hydration, which help to maintain skin integrity.
Obtain physical therapist (PT), occupational therapist (OT), or wheelchair clinic referral for cushion reevaluation if signs of pressure emerge.
• Emphasize importance of weight shifts every 15 minutes with safety belts in place (leaning forward/laterally) for about 2 minutes for clients with paralysis with ability to move the trunk of their body.
• Ensure that client and family know how and when to relieve weight bearing and the importance of pressure relief program and demonstrate compliance with it.
• Utilize a passive standing position of wheelchair to relieve weight bearing, or, if applicable, manually stand client or use a sit-to-stand lift with sling for a few minutes.
• Routinely assess client’s sitting posture and frequently reposition him/her into alignment.
• Sit dysphagic clients as upright as possible in individualized wheelchair versus geri-chair when eating.
• Implement use of friction-coated projection hand rims and leather gloves for clients to propel manual wheelchairs.
• Manually guide or explain how to push forward on both wheel rims to move ahead, push the right rim to turn left and vice versa, and pull backward on both wheel rims to back up.
• Recommend that clients back wheelchairs into an elevator. If entering face first, instruct them to turn chair around to face the elevator doors.
• Reinforce principle of descending a curb backward (“popping a wheelie”) if balance, trunk control, strength, and timing are adequate.
• Ascend curbs in a forward position by popping a wheelie or having aide tilt chair back, place front wheels over curb, and roll chair up. If surface is muddy or sandy, ascend backwards.
• During assisted wheelies, helper must hold wheelchair until all four wheels are back on the ground and client has control of wheelchair.
Follow therapist’s recommendations for how clients should propel manual wheelchairs to prevent upper extremity pain and joint degeneration.
Inform clients that ultra-lightweight, pushrim-activated, power-assisted, or electric wheelchairs may be more therapeutic than manual ones.
• Help clients transition from a manual to a powered wheelchair/scooter if progressive disability occurs.
Reduce floor clutter and establish safety rules for drivers of electric/power mobility devices; make referrals to PT or OT for driver reevaluations if accidents occur or client’s health deteriorates.
• Request and receive client’s permission before moving unoccupied wheelchair in room or out to hallway.
• Reinforce compensatory strategies for unilateral neglect and agnosia (visual scanning, self-talk, self-questioning as to what could be wrong) as clients propel wheelchair through doorways and around obstacles. Refer to care plan for Unilateral Neglect.
• Offer support to help clients cope with issues related to physical disability.
• Provide information on support group and Internet resource options.
• Provide information about advocacy, accessibility, assistive technology, and issues under the Americans with Disabilities Act.
Make social service or wheelchair clinic referral to educate clients on financial coverage/regulations of third-party payers and Health Care Financing Association for wheelchairs.
• Suggest that clients test-drive wheelchairs and try out cushions/postural supports before purchasing them.
• Avoid using restraints on fidgeting clients who slide down in a wheelchair; rather, assess for deformities, spinal curvatures, abnormal tone, discomfort, and limited joint range.
• Ensure proper seat depth/leg positioning and use custom footrests (not elevated leg rests) to prevent elders from sliding down in wheelchairs.
Assess for side effects of medications and potential need for dosage readjustments to increase wheelchair tolerance.
• Allow client to propel wheelchair independently at his or her own speed.
• Assess home environment for barriers and a support system for emergency and contingency care (e.g., Lifeline).
• Recommend the following changes to the home to accommodate the use of a wheelchair:
Arrange traffic patterns so they are wide enough to maneuver a wheelchair.
Recognize that a 5-foot turning space is necessary to maneuver wheelchairs; doorways need to be 32 to 36 inches wide; and entrance ramps/paths should slope 1 inch per foot.
Replace door hardware with fold-back hinges, remove doorway encasements (if too narrow), remove/replace thresholds (if too high), hang wall-mounted sinks/handrails, grade floors in showers for roll-in chairs, use nonskid/nonslip floor coverings (e.g., nonwaxed wood, linoleum, or Berber carpet).
Rearrange room functions, furniture, and storage so that toileting, sleeping, bathing, and preparing/eating meals can safely take place on one level of the home.
Request PT/OT referrals to evaluate wheelchair skills and safety, to suggest home modifications and ways to propel wheelchairs on irregular surfaces and get back into a chair after a fall.
• Suggest community resources for servicing and tuning up wheelchairs and/or locating parts so clients can service their own chairs; an annual tune-up is recommended.
Client/Family Teaching and Discharge Planning
Assess pain levels of long-term wheelchair users and make referrals to therapists or wheelchair clinics for modifications as needed.
• Instruct and have client return demonstrate re-inflation of pneumatic tires; encourage client to monitor tire pressure every 2 to 3 weeks.
• Instruct family/clients to remove large wheelchair parts (leg rests, armrests) when lifting wheelchair into car for transport; when reassembling it, check that all parts are fastened securely and temperature is tepid.
• Teach the importance of using seatbelts or chair tie-downs when riding in motor vehicles in a wheelchair. If unavailable, clients in wheelchairs should be transported in large heavy vehicles only.
• For further information, refer to care plan for Impaired Transfer Ability.
Moral Distress
Defining Characteristics
Expresses anguish (e.g., powerlessness, guilt, frustration, anxiety, self-doubt, fear) over difficulty acting on one’s moral choice
Related Factors (r/t)
Conflict among decision makers; conflicting information guiding ethical decision-making; conflicting information guiding moral decision-making; cultural conflicts; end-of-life decisions; loss of autonomy; physical distance of decision maker; time constraints for decision-making; treatment decisions