00085 Deterioration Of Physical Mobility

Domain 4: activity/rest
Class 2: activity/exercise
Diagnostic Code 00085
Nanda label: deterioration of physical mobility
Diagnostic focus: mobility
Approved 1973 • Revised 1998, 2013, 2017 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « deterioration of physical mobility is defined as: limitation of the independent and intentional movement of the body or one or more limbs.

Definite characteristics

  • Alteration of the march
  • Decrease in fine motor skills
  • Decrease in thick motor skills
  • Decrease in the amplitude of movements
  • Difficulty turning
  • Implicate in substitutions of the movement
  • Express discomfort
  • Tremor induced by movement
  • Postural instability
  • Prolongation of reaction time
  • Slow of movement
  • Spastic movements
  • Uncoordinated movements

Related factors

  • Anxiety
  • Body mass index> appropriate 75
  • Cognitive dysfunction
  • Cultural beliefs regarding acceptable activity
  • Decrease in activity tolerance
  • Decrease in muscle control
  • Decrease in muscle strength
  • Lack of use
  • Support of the inappropriate environment
  • Inappropriate knowledge of the value of physical activity
  • Insufficient muscle mass
  • Insufficient physical resistance
  • Joint stiffness
  • Malnutrition
  • Neurocomportal manifestations
  • Pain
  • Loss of physical condition
  • Resistance to start the movement
  • Sedentary lifestyle

Associated problems

  • Alteration of the integrity of bone structure
  • Contractures
  • Depression
  • Disabilities of development
  • Metabolism deterioration
  • Musculoskeletic deterioration
  • Neuromuscular diseases
  • Pharmacological preparations
  • Restriction of prescribed mobility
  • Sensorioperceptive deterioration

Suggestions of use

  • Deterioration of physical mobility should be used to describe individuals with a limitation in the ability to perform independent physical movements, such as the reduction of the ability to move the arms or legs, a generalized muscle weakness, or when the interventions of Nursing focus on the restoration of mobility and functionality or to prevent greater deterioration. For example, an adequate diagnosis would be deterioration of physical mobility related to an ineffective management of chronic pain due to rheumatoid arthritis.
  • This label should not be used to describe temporary immobility that cannot be modified by nursing activities (such as traction, prescribed absolute rest, etc.) or to describe permanent paralysis. In these cases and in many others, the deterioration of physical mobility can be used effectively as an etiology of a problem.
  • For example, deterioration of tissue integrity (recumbent ulcer) related to a deterioration of physical mobility +4. When appropriate, more specific labels will be used, such as deterioration of mobility in bed ’, deterioration of the ability to transfer-, deterioration of wheelchair mobility, deterioration of the march.

Suggested alternative diagnostics

  • Self -care, deficit of
  • Transfer ability, deterioration of
  • injury, risk of
  • March, deterioration of the
  • Mobility in bed, deterioration of the
  • wheelchair mobility, deterioration of the
  • disuse syndrome, risk of

NOC Results

  • Performance of body mechanisms: personal actions to maintain adequate body alignment and avoid musculoskeletic tension
  • Balance: Ability to maintain body balance
  • Neurological status: Central Motor Control: Central nervous system capacity to coordinate musculoskeletal activity to produce body movements
  • Skeletal function: bones capacity to support the body and facilitate movement
  • March: Ability to walk from one place to another independently, with or without auxiliary devices
  • Mobility: ability to move intentionally in its own environment, independently, with or without the help of a device
  • Joint movement (specify the joint): broad degree of mobility d e _______ (specify the joint) with a movement initiated by the patient
  • Joint movement: Liabilities: Movement of the joints made with help
  • Coordinated movement: Muscles capacity to work voluntarily to achieve an intentional movement
  • Transfer: Ability to change the body location independently, with or without help from a device
  • Patient satisfaction: Functional support: Degree of positive perception of support provided by the nursing professional to achieve mobility and self -care

Evaluation objectives and criteria

Examples with the use of noc> terms

  • demonstrates mobility, as manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Balance
    • Coordination
    • Change of body position
    • Muscle and joint movement
    • Ambulation
    • Displacement without problems

Other examples

  • Demonstrate the correct use of auxiliary devices with supervision
  • Request help for mobilization activities, as required
  • Perform daily activities independently with auxiliary devices (specify activity and device)
  • Weight load
  • Walk with an effective march along d e __________ (specify distance)
  • It moves from or to the chair, or wheelchair
  • Wheel chair effectively handles

NIC Interventions

  • Help in self -care: Transfer: Help a person with limited independent movements to learn to change the location of your body
  • Position: Deliberate placement of the patient, or of a part of his body, to promote physiological and psychological well -being
  • Position: wheelchair: placement of a patient in a wheelchair chosen properly to improve comfort, promote skin integrity and reinforce independence
  • Promotion of bodily mechanisms: Facilitation of the use of postures and movement in daily activities to prevent fatigue and musculoskeletal lesions or tensions
  • Promotion of the exercise: promotion of a regular physical activity to maintain or increase the level of health and physical form
  • Promotion of exercise: strength training: facilitation of muscle training against resistance and regular, to maintain or increase muscle strength
  • Exercise therapy: Muscle control: Use of specific activity or exercise protocols to improve or restore controlled body movement
  • Exercise therapy: Desembling: Promotion and helps the patient to walk, in order to maintain or reestablish the voluntary and autonomous functions of the organism during the treatment and recovery of the disease or injury
  • Exercise therapy: balance: use of specific activities, postures and movements to maintain, improve or restore balance
  • Exercise therapy: joint mobility: use of active or liability body movement to maintain or restore the flexibility of joints

Nursing Activities

  • Evaluation is a continuous process to determine the level of performance of the patient’s physical mobility deterioration.

LEVEL Nursing Activities 1

  • Assess the need for health support in the home and a durable medical team
  • Teach the patient to use and control mobility devices (for example, cane, walker, crutches or wheelchair)
  • Teach him and help him in the transfer processes (for example, from the bed to the chair)
  • Channel to a physiotherapist to prepare an exercise program
  • Provide positive reinforcement during activities
  • Help the patient wearing non -slip footwear to walk
  • (NIC) Position:
    • Teach the patient a good posture and correct body mechanic when performing any activity
    • Monitor the correct placement of traction devices

Nursing activities of Level 2

  • Assess the patient learning needs
  • Assess the need for support from a health center at home and that of a durable medical team
  • Teach and encourage the patient to perform active or passive broad movements exercises, to maintain or develop muscle strength and resistance
  • Teach and encourage the patient to use a trapeze or weights to improve and maintain the strength of the upper extremities
  • Teach you techniques for ambulation and safe transfer
  • Inform the patient about the weight he can bear
  • Inform the patient about the correct body alignment
  • Resort to occupational and physical therapists to develop a maintenance plan or increased mobility
  • Provide positive reinforcement during activities
  • Supervise all mobilization attempts and help the patient, if necessary
  • Use a belt for wandering by helping the patient during march or translation

Nursing activities of levels 3 and 4

  • Determine the patient’s level of motivation to maintain or recover the mobility of joints and muscles
  • Resort to occupational and physical therapists as a resource to plan care activities
  • Motivate the patient and relatives to consider the limitations realistically
  • Provide positive reinforcement during activities
  • Administer analgesics before starting the exercises
  • Develop a plan specifying the following:
    • Type of auxiliary device
    • placement of the patient in bed or in the chair
    • Ways to move and turn the patient
    • Amount of personnel needed to move the patient
    • Required elimination equipment (Silleta, urinal, comfortable)
    • Activity planning
  • (NIC) Position:
    • Monitor the proper placement of traction devices
    • Place the patient in a appropriate therapeutic bed or mattress
    • Place the patient in an adequate alignment of the body
    • Place the patient in the designated therapeutic position (for example, prevent the amputation stump require)
    • Changes of position to the immobilized patient, at least every two hours, according to a specific program, as needed
    • Place the bed positioning switch and alarm light within reach of the patient
    • Encourage the patient to perform active or liabilities exercises, as appropriate .ineciilidros.corn

At home

  • Determine if there are barriers for mobility at home (for example, stairs, irregular floors)
  • Channel to the patient to health services to receive help with the activities of daily life
  • Channel to the patient to physiotherapy services for strength training, balance and march
  • Channel to the patient to occupational therapy services for the use of auxiliary devices
  • Suggest the exercise with a relative or friend
  • Teach the patient to get out of bed slowly

Older adults

  • Monitor immobility complications (for example, pneumonia, recumbent ulcers), which occur more quickly in older people
  • Assess the presence of depression and cognitive impairment
  • Monitor orthostatic hypotension by helping the patient get out of bed, make it balance before standing