Individual Nursing Care Plan

NANDA: Limited range of motion and difficulties while carrying out activities of daily living are symptoms of impaired physical mobility caused by weakened muscles and poorer coordination.

Data

Subjective Data: The patient claims to feel weak and finds it challenging to carry out daily tasks like dressing and walking. Due to their limited mobility, the patient exhibits frustration and a loss of freedom.

Objective Data: The lower extremities’ limited range of motion was noted during a physical examination. The patient struggles to stand up from a seated posture and needs assistance.

Historical Data: The lifestyle of inactivity and irregular exercise; Injury to the knee in the past, which restricted mobility and muscular strength.

Interventions

RN will support and encourage the patient to perform frequent range-of-motion exercises, which include soft stretches and flexion-extension motions of the afflicted joints, such as the knee and hip (Smith, 2019).

Rationale: By strengthening muscles, increasing mobility, and improving joint flexibility, range-of-motion exercises can help people become more independent in their daily lives.

RN will inform the patient about the value of leading an active lifestyle and getting regular exercise. Encourage her to engage in physical activities like cycling, swimming, or walking (American Heart Association, 2020).

Rationale: Regular exercise increases muscle strength, stamina, and general physical functioning, boosting mobility and independence.

RN will work with the physical therapist to create a patient-specific exercise program that emphasizes strengthening and coordination of the lower extremities. Regularly track and record the patient’s improvement—managing the Adult Patient Undergoing Physical Therapy Following Lower Limb Amputation (American Physical Therapy Association, 2019).

Rationale: A physical therapist-designed structured exercise program targets particular muscle groups, improves coordination, and fosters functional mobility, improving overall physical independence.

Take part in regular physical activity, such as brisk walking, jogging, or yoga, for at least 30 minutes most days of the week (American Heart Association, 2020).

Rationale: Regular exercise helps lower stress hormones, elevates mood, and encourages sounder sleep.

Use guided meditation apps or mindfulness exercises to practice mindfulness meditation for 10 minutes daily (American Physical Therapy Association, 2019).

Rationale: Mindfulness meditation helps people become more self-aware, decreases anxiety, and enhances general well-being.

Evaluation: 

SMART goal: Within four weeks, the patient will develop physically and become more independent in daily living activities. By sticking to a balanced diet and exercise routine, the patient will reduce their blood pressure to below 130/80 mmHg in three months.

Evaluation: Partially met

In terms of improved muscle strength and range of motion, the patient has made progress. She can now carry out several everyday tasks on her own, such as getting dressed and going a short distance. To achieve full independence in all areas, nevertheless, more development is needed.

Continuation Plan

1. Exercises for a range of motion should be continued, with the intensity and time gradually increasing as tolerated.
2. The patient should follow the physical therapist’s suggested exercise regimen.
3. Regularly assess the patient’s progress and modify the care plan as required.
4. Assist the patient with continued education and support about the value of leading an active lifestyle and exercising frequently
5. Schedule regular medical checkups to keep an eye on the patient’s development, address any worries, and, if required, modify my care plan.
6. The patient must consult a trained dietitian or nutritionist for assistance if she needs more advice or information on developing healthy eating habits.
7. Join a fitness class or participate in other enjoyable physical activities to keep a regular exercise schedule.

References

American Heart Association, (2020). Physical Activity and Your Heart.

American Physical Therapy Association, (2019). Physical Therapy Management of the Adult Patient with Lower Limb Amputation.

Smith, J. (2019). Physical Therapy Interventions; An Evidence Based Approach. Philadelphia, PA:F.A. Davis Company.