Diagnosing – use NANDA list

Diagnosing – use NANDA list

1. impaired physical mobility

2. self-care deficit

3. situational low self-esteem

4. activity intolerance

Planning

1. planning - for positioning

2. transferring – lock wheels on wheelchair

3. ambulatory – clutter out of the way

4. planning- for home care (walker, cane)

5. bedrest – limbs supported, turn every 2 hrs.

Implementing: Transferring a Client from Bed to Wheelchair

1. inform client what you are doing

2. lock wheels on wheelchair

3. assist client to dangle on side of bed

4. assist client to standing position & pivot to chair

5. place client's hands on arm supports

6. bend at knees, easing client into chair

Preventing Back Injury

1. stand with a broad base of support

2. tighten abdominal muscles

3. tighten gluteal muscles

4. use large muscles to lift

5. keep objects close to body within base of support

Positioning Clients

1. Fowler's position

2. orthopneic position – (breathe easier) – sit with hands on table to support upper body can expand lungs easier

3. dorsal recumbent position – on back

4. prone position – on stomach

5. lateral position

6. Sim's position

7. moving & turning patients in bed – use support, pillows, foot board

Prevention is the Key

Incorporating physical activity

1. reduces stress

2. improves glycemic control

3. moderates weight

4. improves posture

5. helps prevent osteoporosis

   
   

Considering Restraints – use only as last resort, less restrictive measures better, must monitor

1. mitts

2. wrist restraints

3. vest or Posey