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Nursing Care Plan: Risk For Disuse Syndrome

Peter Chan is a 69-year-old man with congestive heart failure who has decreased mobility due to dyspnea. He works from home and sits for most of the day. The nurse has assessed him to be at risk for disuse syndrome due to his decreased activity level and obesity. The nurse's care plan focuses on positioning Chan to alleviate dyspnea and encouraging range of motion exercises to prevent loss of muscle strength and mobility issues. The nurse will also collaborate with therapists to develop an individualized exercise program and provide visual aids and step-by-step instructions to help Chan perform exercises. The goals are to prevent issues like pressure ulcers and decreased mobility.

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Rozsy Fakhrur
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3K views

Nursing Care Plan: Risk For Disuse Syndrome

Peter Chan is a 69-year-old man with congestive heart failure who has decreased mobility due to dyspnea. He works from home and sits for most of the day. The nurse has assessed him to be at risk for disuse syndrome due to his decreased activity level and obesity. The nurse's care plan focuses on positioning Chan to alleviate dyspnea and encouraging range of motion exercises to prevent loss of muscle strength and mobility issues. The nurse will also collaborate with therapists to develop an individualized exercise program and provide visual aids and step-by-step instructions to help Chan perform exercises. The goals are to prevent issues like pressure ulcers and decreased mobility.

Uploaded by

Rozsy Fakhrur
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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koz74686_ch44.

qxd

11/8/06

6:15 PM

Page 1158

1158 UNIT X / Promoting Physiologic Health

NURSING CARE PLAN

Risk for Disuse Syndrome

ASSESSMENT DATA

NURSING DIAGNOSIS

DESIRED OUTCOMES*

Nursing Assessment
Peter Chan, a 69-year-old, unmarried accountant being treated for
congestive heart failure, states he has dyspnea with mild activity.
(I cannot climb a flight of stairs without stopping and resting and
become breathless even when walking on level ground.) Prefers
the orthopneic position. He works at home and sits at a table for
most of the day.

Risk for Disuse Syndrome related to decreased activity resulting from inadequate
balance between oxygen supply and demand associated
with decreased cardiac output
and obesity.

Immobility Consequences:
Physiological [0204], as evidenced by no
Pressure ulcers
Decreased muscle strength

Physical Examination

Diagnostic Data

Height: 178 cm (510)


Weight: 102 kg (225 lb)
Temperature: 37.8C (100.4F)
Pulse rate: 94 BPM
Respirations: 20/minute
Blood pressure: 174/92 mm Hg
Rales present in both lungs.
Respirations slightly labored.
Color pale.
3+ (5 mm) edema both feet
and ankles

CBC, and urinalysis within


normal limits.

Mobility [0208], as evidenced


by mildly compromised
Walking
Balance

CXR reveals an enlarged


heart.

NURSING INTERVENTIONS*/SELECTED ACTIVITIES

Immobility Consequences:
Psycho-cognitive [0205], as evidenced by no
Apathy
Sleep disturbances
Negative body image

RATIONALE

Positioning [0840]
Position to alleviate dyspnea, e.g., high Fowlers.

Clients with increased pulmonary secretions are able to breathe


better when upright because abdominal organs are lower and
there is greater room for lung and diaphragmatic excursion.

Provide support to edematous areas, e.g., elevate feet on foot


stool when sitting.

Elevating the dependent area assists with decreasing tissue pressure and promoting fluid return to the venous system and the heart.

Encourage active range of motion exercises.

Active ROM helps keep muscles in current strength and promotes circulation. Mild activity also helps burn unneeded calories.

Exercise Therapy: Muscle Control [0226]


Collaborate with physical, occupational, and recreational therapists
in developing and executing an individually tailored exercise
program.

This client will need a multidisciplinary approach to his care. Each


member contributes from his or her area of expertise. Research
supports efficacy of individually tailored exercise plans. Factors
such as having an exercise partner, using music, and type of activity can motivate client and enhance adherence to the plan
over time.

Offer options, explain rationale for type of exercise and protocol to


client, and allow him to make choices that appeal to him and that
address his needs.

If the client understands what the reasons are for activity, he can
make good choices.

Provide step-by-step cuing for each motor activity during exercise


or ADLs.

As-needed reminders help the client recall what to do next.

Use visual aids to facilitate learning how to perform exercises.

Some people have better visual memory than auditory memory.

EVALUATION
Outcomes met. Mr. Chan did not develop any skin breakdown or other evidence of the complications of immobility to date. However,
since the risk factors remain, the care plan will be ongoing.
*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention.
Outcomes, indicators, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

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6:15 PM

Page 1159

CHAPTER 44 / Activity and Exercise 1159

APPLYING CRITICAL THINKING


NURSING CARE PLAN Risk for Disuse Syndrome (continued)

3. The care plan does not address one of Mr. Chans risk factors
obesity. Would you add this to the plan?
4. What assumptions has the nurse made in assigning the desired
outcome of Immobility Consequences: Psycho-Cognitive?
5. How are the choices of outcomes influenced by the cause of his
nursing diagnosis (a chronic illness)?

1. What assessment findings alert you that Mr. Chan is developing problems associated with his current state of decreased
mobility?
2. Mr. Chan may benefit from using a walker to assist with ambulation
at home. What teaching should be done in regard to use of a
walker?

See Critical Thinking Possibilities in Appendix A.

CONCEPT MAP

Client at Risk for Disuse Syndrome

PC
69 y.o. male
CHF

Unmarried accountant: works at home


c/o dyspnea on exertion
Height: 178 cm (5' 10")
Weight: 102 kg (225 lb)
Temperature: 37.8C (100.4F)

assess

Pulse rate: 94 BPM


Respirations: 20/minute
Blood pressure: 174/92 mm Hg
CBC and urinalysis within normal limits
CXR shows enlarged heart

generate nursing diagnosis

Risk for Disuse Syndrome r/t decreased activity resulting from inadequate
balance between oxygen supply & demand associated with decreased CO and obesity

Outcomes met:
Did not develop
any skin
breakdown or
other evidence of
the complication
of immobility to
date

evaluation

outcome

outcome

Immobility Consequences:
Physiological aeb no:
Pressure ulcers
Decreased muscle strength

Mobility aeb
mildly compromised:
Walking
Balance

nursing intervention

nursing intervention

Positioning

Position to alleviate
dyspnea (e.g., high
Fowler's)

Provide support to
edematous areas, e.g.,
elevate feet on foot
stool when sitting

Exercise Therapy-Muscle Control


activity

activity

activity
activity

activity
activity

Encourage active
range-of-motion
exercises

evaluation

Outcomes met:
Did not develop
any compromised
muscle function
However, since
the risk factors
remain, the care
plan will be
ongoing

Use visual aids


to facilitate
learning how to
perform exercises

Provide step-by-step
cuing for each motor
activity during exercise
or ADLs

activity
Collaborate with physical
occupational, and recreational
therapists in developing and
executing exercise program

Explain rationale
for type of exercise
and protocol to client

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