The patient had recently undergone surgery on their left lower extremities and was experiencing pain and limited range of motion. The nurse assessed the patient and identified the nursing diagnosis of impaired physical mobility related to loss of limb. The nurse's plan was to monitor the patient, ensure a safe environment, encourage use of mobility devices, and perform range of motion exercises to improve mobility over the short and long term. The goals of understanding instructions and demonstrating improved exercises were both met after nursing intervention.

1. ASSESSMENT NURSING
DIAGNOSIS
PLANNING NURSING
INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE DATA:
“Hindi ako masyado
makagalaw at sumasakit yung
inoperahan sa aken” as
verbalized by the patient
OBJECTIVE DATA:
- Report discomfort
and pain upon
movement
- Limited range of
movement
- With surgical dressing
on left lower
extremities
- Facial grimace when
trying to move
PR: 95 bpm
RR: 18 bpm
TEMP: 36.4
BP: 120/90 mmHg
Weight: 45 kg
Height: 170 cm
Impaired physical mobility
related to loss of limb
(particularly left lower
extremities)
SHORT TERM
After 1 hour of nursing
intervention the client will
verbalize understanding of his
situation, prescribed
therapies, and safety
measures. Also, the client will
display willingness to
participate in activities.
LONG TERM
After 3 days of nursing
intervention the client will
demonstrate exercises to
improve physical mobility
INDEPENDENT
1. Monitor the client’s vital
signs.
2. Provide a safe environment
by raising the side rails up,
bed in a down position, and
important items close by.
3. Assess strength and range
of motion.
4. Encourage the use of
mobility devices, such as the
trapeze, prosthetic legs and
crutches.
5. Inspect dressings, wounds
and note the characteristics
of drainage.
6. The limb should be
elevated 24 hours after the
amputation.
7. Encourage active/isometric
exercises for upper torso and
unaffected limbs.
INDEPENDENT
1. This will serve as baseline
data and to monitor any
irregularities.
2. These measures promote a
safe, secure environment and
may reduce the risk for falls.
3. Assessing the patient’s
range of motion prior to
movement will show the
nurse what the patient is or is
not capable of.
4. These devices can
compensate for impaired
function and enhance the
level of activity.
5. Early detection of
developing infection provides
an opportunity for timely
intervention and prevention
of more serious
complications.
6. To enhance the venous
return and decrease edema.
7. Increases muscle strength
to facilitate
transfers/ambulation and
SHORT TERM
After 1 hour of nursing
intervention the client
verbalize understanding of his
situation, prescribed
therapies, and safety
measures. Also, display
willingness to participate in
activities.
LONG TERM
After 3 days of nursing
intervention the client
demonstrate exercises to
improve physical mobility.
Therefore, the goal was met.

2. 8. Provide trochanter rolls as
indicated.
DEPENDENT
1. Administer pain medication
as prescribed.
COLLABORATIVE
1. Collaborate with the
rehabilitation team.
promote mobility.
8. Prevents external rotation
of lower-limb stump
1. To alleviate the pain or
discomfort
1. Impaired mobility may
require the support of PT and
OT to instruct on exercises
and perform activities that
stimulate muscle control and
fine motor movement.