The table below provides a Impaired physical mobility care plan, outlines the SMART goals of treatment and nursing interventions for osteoporosis, and provides a methodology for accessing the findings.(Impaired physical mobility care plan)
For a more detailed analysis, you can also read Osteoporosis Nursing Diagnosis, Nursing Care Plan and Nursing Interventions
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Impaired physical mobility Head to Toe Assessment (SOAP NOTE Assessment for a patient with Impaired physical mobility)
Patient: The patient is a 49 years old woman who presents with back pain and swollen upper thigh/hip.
CC: The patient complains of back pain, swollen hip, and significant weight loss in the last two and a half months. The Caucasian female visits the office with concerns over prolonged back pain, significant weight loss, and stopped posture. She reports that mild pain started three months ago but became more severe in two weeks. Her upper leg was hit by a chair one day ago, causing swelling. She expected the pain and swelling to go away, but it persisted, hence seeking medical care. The patient also reports that she had fractured two times last year, and mild traumas caused all. She says that the pain is aggravated by minimal activities such as walking short distances, bending, and carrying out daily house chores with no relieving factors. She rates the pain as 8/10. She reports that she has also lost significant weight despite eating the same food without engaging in physical activity. The patient reports that she cannot perform some ADLs due to pain and limited mobility. However, the patient denies loss of height, chills, headache, and tingling of feet. She is also not on medication but took Tylenol for pain before she decided to come for help. Impaired physical mobility SOAP NOTE Assessment(Impaired physical mobility care plan)
PMH: Pneumonia during childhood, bone fractures
Surgical History: myomectomy six years agoAllergy: No known allergiesImmunizations: The patient took a flu shot in 2019.
Personal History: Married with two children and live together in their apartment. The patient denies smoking or alcohol use.
Family History: Father (deceased) had diabetes and hypertension. The mother has osteoporosis.
Review of Systems: Subjective (Impaired physical mobility SOAP NOTE Assessment )
General: The patient denies headache, bruises, and chills but reports fever and is concerned about weight loss
HEENT: Head- the patient, denies headaches, hair loss, or notable masses. Ears- the patient reports no changes in hearing, ear discharge, or ringing in years. Eyes: The patient denies blurry vision but uses eyeglasses for reading. Nose-the patient denies congestion, nose bleeds, and dryness. Mouth: The patient denies bleeding gums, decayed or missing teeth, odors, and dryness. Neck: the patient denies swelling and enlarged lymph nodes, pain or difficulty swallowing, and stiffness. Throat: patient denies sore throat, erythema(Impaired physical mobility care plan)
Cardiovascular: the patient denies chest pains or discomforts, fast/slow heart rates, and cold feet/hands. The patient reports swelling of the lower limb.
Respiratory: The patient denies chest tightness, wheezing, pain, consistent coughs, and breathing difficulties.
Skin: The patient denies discoloration, bruising, lumps, and open wounds
Gastrointestinal: The patient denies constipation, abdominal pain/discomfort, heartburn, nausea,bowel movement changes, guarding and tenderness, and distension.
Musculoskeletal: The patient denies back tenderness, stiffness, and joint swelling but reports back pain, limited ROM due to swelling at the hip area, and inability to bear weights.(Impaired physical mobility care plan)
Neurological: The patient reports stooped posture and deny memory loss, tremors, severe headaches, and loss of consciousness.Endocrine: The patient denies swollen glands, excessive sweating, thyroid problems, and reports weight loss.
ROS: Objective Data
Vitals: T: 98.6F, BP: 125/82, Pulse: 85, W: 132, H: 5’4”, RR: 18
General: The patient appears distressed but alert and oriented to place and time. She shows limited movement. Her speech is soft with a clear tone.(Impaired physical mobility care plan)
HEENT: Head: size and symmetry are normal on inspection, and hair is clean and fine. The scalp has no lesions and no tenderness noted on palpation. Eyes: has high eye acuity, pupils react to light, they are equal and round. The sclera is normal, white, and moist. No discharge was noted. The patient wears glasses. Ear: External year position and shape is normal on inspection. No drainage was noted, and both years can hear. Nose: There is no drainage present, and patency is adequate. Mouth: lips are pink, the oral cavity is moist with no phlegm, the gums are pink and moist, and the patient has all teeth. The tongue is red with no cracks or sores. Neck: ROM is full,no masses on palpation.
Cardiovascular: no murmurs, clicks hear on auscultation. S1, S2 are normal with regular heart rhythm and heart rate. Capillary refill is less than 2 seconds. (Impaired physical mobility SOAP NOTE Assessment)
Respiratory: normal breath sounds with no wheezing on auscultation. Respirations are effortless and regular.
Musculoskeletal: The patient moves around the room with difficulty and reports pain in the back and hip area when moving. The patient reports pain on bending.
Neurological: the patient has a stooped posture on observation with unstable balance. Speech is clear with a good tone. She answers questions appropriately.(Impaired physical mobility care plan)
Gastrointestinal: no masses or tenderness of abdomen on palpation, the abdomen is not distended, and bowel sounds are positive and normal on all four quadrants.
Assessment Outcomes for the Impaired physical mobility care plan
Following the assessment of subjective and objective data, the primary diagnosis for the 49 years old woman is osteoporosis. This is supported by bone weakness which could be causing back pain due to a possible fracture of the vertebra. Also, the thigh bone’s swelling at the hip area could be due to a hip fracture. The patient also has a stooped posture due to a possible back fracture and pain. The patient also has a history of bone fractures, including a family history of osteoporosis. A dual-energy ray absorptiometry (DXA) can be performed to confirm the diagnosis (Mayo Clinic, 2019) (Impaired physical mobility SOAP NOTE Assessment )
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Impaired physical mobility care plan Example with SMART goals nursing students guide (nursing diagnosis impaired physical mobility )
| Nursing Diagnoses(impaired physical mobility nursing diagnosis) | Smart Goals for a impaired physical mobility nursing diagnosis | Nursing Interventions for impaired physical mobility nursing diagnosis | Evaluative Findings for impaired physical mobility nursing diagnosisImpaired physical mobility SOAP NOTE Assessment |
| 1. Impaired physical mobility and impaired physical mobility nursing diagnosis | Short-term goals in Impaired physical mobility care plan1. Relieve the
patient from pain. Specific: the goal is to relieve pain where the patient should verbalize pain relief in the next 1 hour. This goal is crucial since pain causes discomfort, distress, and distraction. Resources needed for pain include pain medication and emotional support. The nurse will be involved in the process. Measurable: the goal is measurable and tracked on a 1 to 10 pain scale. The goal will be achieved when the patient verbalizes pain lower than 3/10. Achievable: The goal can be achieved since the nurses have the required skills and resources. Also, following the right pain protocol will help achieve the goal.(Impaired physical mobility care plan) Relevant: The goal is appropriate for the condition since the patient reports pain at the hip and back. Timely: The plan will remain effective for an hour after complaints of pain |
1. Assess pain levelsusing a 1-10 rating
scale and determine the location, severity, and quality of pain 2. Provide appropriate pain management medication as instructed, such as morphine. |
Goals met· The patient verbalized relief from pain on a scale of 2/10 in 45minutes.
· The patient responds to morphine · The patient seems relaxed · The patient participates in activities with minimal discomfort |
| Impaired physical mobility care plan and impaired physical mobility nursing diagnosis | 2. Provide knowledge about the conditionSpecific. The patient will verbalize the understanding of her condition and its management plan. This goal is crucial since it will help prevent falls, injuries, infection, and deterioration. Resources needed include learning tools such as brochures, videos, and leading nurses.
Measurable. The goal is measurable since the patient will be required to verbalize the required information about the condition. The goal will be achieved when the patient teach-back all the needed information. Achievable. The goal is achievable since the care center, and nurses have all resources and knowledge to address the knowledge gap. The patient will achieve this by following the 1. Instructions given.(Impaired physical mobility care plan) Relevant. The goal is appropriate since knowledge could slow healing due to poor compliance. Also, the patient could fail to ask for assistance when turning, walking which makes the intervention vital. Timely. This goal will last in the first week of treatment |
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| Impaired physical mobility care plan and impaired physical mobility nursing diagnosis | Intermediate goals1. Prevent infections
Specific. The goal is to reduce the risk of infection while at the hospital by achieving timely wood healing.(Impaired physical mobility care plan) This goal is crucial since the current state exposes her to infections that could lead to complications such as sepsis, shock, and death. Measurable. The goal will be measured by inspecting the patient for infection signs such as purulent drainage and erythema. Regular blood work will also help track outcomes. The goal will be achieved if the patient does not acquire any infection. Achievable. This goal is achievable if healthcare professionals follow appropriate infection prevention protocols such as frequent handwashing, sterile equipment, and PPEs. The care facility also has the needed resources to achieve the goal.(Impaired physical mobility care plan) Relevant. Preventing infections is an appropriate goal for the patient since infections could compromise skin integrity and increase complications. Timely. This goal is effective during the first weeks of healing when infection risk is high |
1. Provide wound care as required in the protocol and use sterile equipment during care to prevent contamination2. Assess the skin and pin sites for signs of infection such as fever, swelling, redness on the hip joint, foul odor, edema, and erythema. Also, the nurse should investigate pain since it could indicate infection |
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| Impaired physical mobility care plan and impaired physical mobility nursing diagnosis | 2. Maintaining skin integritySpecific. The goal is to maintain skin integrity by demonstrating techniques to prevent skin breakdown. The goal is important to ensure the skin remains intact to prevent complications such as infection with necrosis and death (Murphree, 2017). The patient and nurses will be responsible for achieving this goal, and resources needed include hospital equipment, pillows, appropriate bed, and others.
Measurable. The goal will be measured by inspecting and documenting the skin condition in every shift. Capillary refill on toes/fingers, skinturgor and sensitivity will be assessed. The goal will be achieved if the patient heals without cases of skin breakdown. Achievable. The goal is achievable since nurses have the knowledge, skills, and protocols to maintain skin integrity. The required resources are also available. Relevant. This goal is essential and appropriate since it will help prevent the hip area or the back. The outcome will also meet the current needs of the patient Time. This goal is appropriate for the first few weeks of treatment during the healing process |
1. The nurse will give skincare and examine the skin for discolouration, open wounds, rashes, and bleeding to get information about skin circulation2. The nurse will ensure the patient is repositioned
nursing diagnosis impaired physical mobility |
· The patient verbalizes leg comfort· The patient is achieving timely healing
· The pressure is being minimized on the legs and back. · Skin integrity is intact nursing diagnosis impaired physical mobility |
| Impaired physical mobility care planimpaired physical mobility nursing diagnosis | Long term Goals1. Reduce the risk for trauma, falls, and injury
Specific. The patient will be protected from falls and injuries during treatment. The goal is essential since falls and injuries would cause complications leading to slow healing. The nurse, physical therapist, and the patient will be involved. Resources needed include ambulatory aids and environmental safety. Measurable. The goal will be measured by inspecting the patient for injuries, recording fall incidents, and achieving outcomes if no falls and injuries are recorded during the treatment period Achievable. The outcome can be achieved if appropriate resources are utilized and followed by fall prevention protocols. Relevant. Preventing falls and injuries is crucial to maintain skin integrity and prevent infections and other complications. Also, the goal is relevant since falls are among the most significant causes of morbidity and mortality in hospitals (AHRQ, 2019). The patient’s condition also exposes her to fall and injury risks Time. This goal will remain effective during the whole treatment period |
1. The nurse should provide limb rest and joint support topromote stability and comfort2. Assess the need and instruct the patient to use ambulation aids such as a walker, crutches. Also, assist the patient in walking or turning to prevent falling
impaired physical mobility care plan |
· The patient is free from falls and injuries· The patient utilizes walkers and crutches whenwalking around
· The patient is stable at the fracture site · The patient asks for help/support when standing. impaired physical mobility care plan |
| impaired physical mobility nursing diagnosis | 2. Prevent mobility complicationsSpecific. The patient will be helped to achieve ROM to improve functional mobility and increase muscle strength. This goal is essential since it improves circulation and ensures the patient maintains ROM. The patient, family, and physical therapist will be involved in the process.
Measurable. The goal will be measured by documenting successful movements and the frequency and length of ambulation. The outcome will be achieved when the patient performs ROM, ambulates, and carry out ADL independently without limited ROM or discomfort. Achievable. The outcome can be achieved since the care facility has the resources and personnel such as therapists and nurses to help realize the goal. Relevant. The goal is relevant since improving ambulatory ability, and ROM will improve circulation, muscle strength, prevent discomfort and injuries. The patient needs to be able to walk without falling. Timely. The timing for this goal is throughout the treatment period while at the hospital and home. |
1. Assess the patient’s degree of mobility and ROM to help establish a care plan.impaired physical mobility care plan2. Provide isometric and ROM exercises during every shift to prevent joint contractures on the affected leg
impaired physical mobility care plan |
· The patient maintains ROM· The patient maintains tolerable functional mobility
· The patient uses adaptive changes for ambulation impaired physical mobility care plan |
Conclusion to the Impaired physical mobility care plan
Considering that osteoporosis is associated with weak and brittle bones prone to fractures, nursing interventions aim to prevent risks and complications associated with the condition to ensure the patient receives proper management. Following the success of the various interventions in the care plan, the most appropriate intervention would be using an appropriate drug regimen as instructed and a dietary intervention approach. For instance, intervention with bioposphates such as Alendronate, risedronate, zoledronic acid, and others, which are first-line treatments for the condition, can help modify bone loss risk factors. For instance, studies show that the drugs reduce osteoclast activity, which ensures slowed removal of old bone and improves bone density and strength (Upham, 2019).
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impaired physical mobility care plan
On the other hand, dietary intervention is critical since it complements drug therapy. Research shows that proteins play a crucial role in strengthening muscle tissues; calcium improves bone strength and density, while vitamin C and D promote calcium absorption in bones (Higgs et al., 2017). In this case, foods rich in these nutrients can help develop stronger and dense bones, reduce bone fracture risk, falls, and effectively manage osteoporosis. A combination of medication and diet can go a long way to improve patients’ health and wellbeing.
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References to Impaired physical mobility care plan
AHRQ. (2019). Falls: Patient Safety Primer. Agency for Healthcare Research and Quality. Retrieved from https://psnet.ahrq.gov/primer/falls
AHRQ. (2019). Falls: Patient Safety Primer. Agency for Healthcare Research and Quality. Retrieved from https://psnet.ahrq.gov/primer/falls
Mayo Clinic. (2019). Osteoporosis. Retrieved from https://www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968
Muir, A. J., Sanders, L. L., Wilkinson, W. E., & Schmader, K. (2001). Reducing medication regimen complexity: a controlled trial. Journal of general internal medicine, 16(2), 77–82. https://doi.org/10.1046/j.1525-1497.2001.016002077.x
Murphree R. W. (2017). Impairments in Skin Integrity. The Nursing clinics of North America, 52(3), 405–417. https://doi.org/10.1016/j.cnur.2017.04.008
Upham, B. (2019). Common Osteoporosis Drugs: Safe or Dangerous? Everyday Health. Retrieved from https://www.everydayhealth.com/news/osteoporosis-drugs-safe-dangerous/
Vera, M. (2019). Fracture Nursing Care Plans. Nurselabs. Retrieved from https://nurseslabs.com/8-fracture-nursing-care-plans/6/
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