00090 Deterioration Of The Ability To Translation

Domain 4: activity/rest
Class 2: activity/exercise
Diagnostic Code: 00090
Nanda label: deterioration of the ability for translation
Diagnostic focus: translation ability
Approved 1998 • Revised 2006, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « deterioration of the ability to translation is defined as: limitation of independent movement between two nearby surfaces.

Definite characteristics

  • Difficulty transferring between bed and chair
  • Difficulty transferring between bed and standing
  • Difficulty transferring between the car and the chair
  • Difficulty transferring between the chair and the floor
  • Difficulty transferring between the chair and standing
  • Difficulty transferring between soil and standing
  • Difficulty transferring between irregular surfaces
  • Difficulty transferring inside or outside the bathtub
  • Difficulty transferring on or off the shower
  • Difficulty transferring to or from a wedge urinal next to the bed
  • Difficulty transferring to or from the toilet

Related factors

  • Cognitive dysfunction
  • Limitations of the environment
  • Postural balance deterioration
  • Inappropriate knowledge of transfer techniques
  • Insufficient muscle strength
  • Neurocomportal manifestations
  • Obesity
  • Pain
  • Loss of physical condition

Associated problems

  • Musculoskeletic deterioration
  • Neuromuscular diseases
  • Vision disorders

Suggestions of use

  • (a) Deterioration of the ability to transfer should be used to describe individuals with a limited ability to perform physical movements independently, such as decreased ability to move arms or legs, or generalized muscle weakness, or When nursing interventions focus on restoring mobility and functioning, or in preventing greater deterioration. This label should not be used to describe temporary states that the nursing professional cannot modify (for example, traction, prescription of bed or permanent paralysis). When it is not possible to improve the patient’s ability to move, this diagnosis should be used as a risk factor or related to another nursing diagnosis, as a risk of falls, (b) specify the level of mobility using the same criteria that are used for the deterioration of physical mobility.
  • Level 0: It is completely independent
  • Level 1: You need the use of some equipment or device
  • Level 2 Requires another person for support, supervision or teaching
  • Level 3: requires help from another person and some device or equipment
  • Level 4: It is dependent; It does not participate in the activity (c) see the suggestions of use for physical mobility, deterioration of the.

Suggested alternative diagnostics

  • Falls, risk of
  • injury, risk of
  • March, deterioration of the
  • Mobility in bed, deterioration of the
  • wheelchair mobility, deterioration of the
  • Physical mobility, deterioration of
  • disuse syndrome, risk of

NOC Results

  • Body placement: self -infected: Ability to change body posture independently, with or without the help of a device
  • Balance: Ability to maintain body balance
  • Coordinated movement: muscles capacity to work voluntarily to achieve a certain movement
  • Transfer: Ability to change body location independently, with or without the help of a device

Evaluation objectives and criteria

  • It demonstrates the ability to move, which is manifested by balance and placement of the body: self -initiated, coordinated movement and transfer of the transfer
  • Other examples

    • The patient carries out a wide variety of movements of all joints
    • The patient will be able to:
    • move from bed to the chair or get out of bed
    • Sit and stop from the toilet or comfortable
    • move from the wheelchair to the car or car to the wheelchair
    • Go from standing to the floor and the floor to stand up

    NIC Interventions

    Note : The following interventions focus on improving the transfer capacity. Other interventions may be required to deal with factors related to diagnosis (for example, visual deficiencies, insecure environment, pain and obesity).

    • Support in self -care: Transfer: Help a person with limited independent movements to learn to change the location of his body
    • Fall prevention: application of special precautions with a patient at risk of drops lesions
    • 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: balance: use of activities, postures and specific movements to maintain, improve or restore balance
    • Exercise therapy: March: promotion and patient help to walk, in order to maintain or restore the voluntary and autonomous functions of the organism during the treatment and recovery of the disease or injury
    • Exercise therapy: joint mobility: use of active or liability body movement to maintain or restore the flexibility of joints

    Nursing Activities

    Valuations

    • Perform continuous evaluations of the patient’s ability to move
    • Evaluate the need for support from an institution for health care or other placement service and assess the need for durable medical equipment
    • Evaluate vision, audition and self -perception
    • (NIC) Exercise therapy: Muscle control.
      • Determine the patient’s arrangement to commit to an activity or exercise protocol
      • Determine the precision of body image
      • Monitor the patient’s functional, emotional and cardiovascular responses, before the exercise protocol
      • Watch that the patient correctly performs the exercises

    Patient and family education

    • Teach passive or active exercises with a wide range of movement
    • Give step by step
    • Provide diagrams and written information
    • Provide frequent feedback to prevent the creation of bad habits
    • Provide information about auxiliary devices that could help in the transfer
    • Teach home caregivers how to incorporate balance and strength exercises to daily life activities
    • (NIC) Exercise therapy: Muscle control.
      • Provide step by step for each motor activity during exercise or activities of daily life
      • Instruct the patient to describe each movement while carrying it out

    Collaboration activities

    • Use occupation and physical therapy as resources when organizing a plan to maintain or increase mobility for transfer; The plan must include exercises for the balance and strengthening of the muscles

    Others

    • Place the light or a call button within reach of the patient
    • Provide positive reinforcement during activities
    • Implement the measures for pain control before starting exercise or physical therapy
    • Ensure that the care plan includes the necessary personnel to transfer the patient
    • Help the patient move, if necessary
    • (NIC) Exercise therapy: Muscle control.
      • Dress the patient with baggy clothes
      • Help the patient maintain the stability of the trunk or the proximal joints during motor activity
      • Reorient the patient in body mobility functions
      • Incorporate activities of daily life in the exercise protocol, if adequate
      • Help the patient prepare and carry a table or graph of their progress, to motivate compliance with the exercise protocol

    At home

    • The above activities can be used or adapted for home care
    • Help the family accommodate the furniture so that allows the greatest possible mobility of the patient