NCLEX-PN

Utilizing Nursing Procedures and Psychomotor Skills When Caring for Clients with Immobility Nursing care encompasses all stages of the nursing process, including assessment, nursing diagnosis, planning, implementation, and evaluation. In the assessment phase, nurses evaluate and reevaluate clients for existing and potential complications related to immobility, as discussed earlier in the section titled "Recognizing the Complications Arising from Immobility." Additionally, nurses assess clients' requirements regarding mobility, gait, strength, and motor skills, as elaborated upon in the section named "Assessing Client Mobility, Gait, Strength, and Motor Skills." The nursing diagnoses concerning immobility hazards and client mobility were also examined in the aforementioned sections. Planning is based on identified actual and potential health problems, followed by the formulation of expected Client outcomes or goals and corresponding interventions. Some anticipated Client outcomes in relation to immobility and mobility encompass specific objectives, such as: ●​ The client will engage in an active range of motion exercises for all joints twice daily. ●​ The client will safely transition from the bed to a chair with assistance. ●​ The client will exhibit freedom from venous stasis. ●​ The client will demonstrate correct deep breathing and coughing techniques. ●​ The client will ambulate a distance of 30 feet three times daily using a walker, assisted by another person.

●​ The client will elevate their level of physical activity and exercise. ●​ The client will showcase proficient usage of their assistive device. ●​ The client will uphold skin integrity. ●​ The client will maintain adequate respiratory function.

The interventions for addressing immobility, focusing on systems prone to adverse effects due to immobility, encompass continuous Client monitoring, assessments, and reassessments for potential risks. These interventions encompass : Urinary System : Ensuring sufficient fluid intake, monitoring, documenting, and evaluating the client's input and output to maintain a proper fluid balance. Gastrointestinal System : Promoting adequate hydration, encouraging a high-fiber diet, motivating out-of-bed activities like ambulation (unless contraindicated), and administering treatments like stool softeners, fiber supplements, enemas, and laxatives as prescribed.

331

© 2025 ACHIEVE ULTIMATE CREDIT-BY-EXAM GUIDE | NCLEX-PN ​

​

​

​

​