Nurse's Pocket Guide

• Involve client/SO(s) in determining activity schedule. Promotes
commitment to plan, maximizing outcomes.
• Encourage continuation of exercises to maintain/enhance
gains in strength/muscle control.
• Obtain/identify sources for assistive devices. Demonstrate
safe use and proper maintenance.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, including level of function/ability to
participate in specific/desired activities.
PLANNING
• Plan of care and who is involved in the planning.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modification to plan of care.
DISCHARGE PLANNING
• Discharge/long-range needs, noting who is responsible for
each action to be taken.
• Specific referrals made.
• Sources of/maintenance for assistive devices.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC—Body Position: Self-Initiated
NIC—Bed Rest Care
impaired physical Mobility
Taxonomy II: Activity/Rest—Class 2 Activity/Exercise
(00085)
[Diagnostic Division: Safety]
Submitted 1973; Nursing Diagnosis Extension and
Classification (NDEC) Revision 1998
Definition: Limitation in independent, purposeful physical
movement of the body or of one or more extremities
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 457
impaired physical MOBILITY