Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: None

Impaired physical mobility r/t Neuromuscular skeletal impairment.

After 8 hours of Nursing Intervention the patient will able to: a. Cooperate with the student nurse in treatment regimen and safety measures. b. Participate in ADLs and desired activities such as eating, maintenance of proper hygiene.

Objective:  Limited ROM  Slowed movement  Inability to perform gross/ fine motor skills.  Gait changes  Difficulty of turning

Assess degree of immobility produced by injury/ treatment and note patient’s perception of immobility.

Patient may be restricted by selfview/selfperception out of proportion with actual physical limitations, requiring information/interv entions to promote progress toward wellness. Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures/atro phy and calcium resorption from disuse. Useful in maintaining functional position of extremities, hands/feet, and preventing complications (e.g., contractures/ foot drop). Improves muscle strength and circulation, enhances patient control in situation, and promotes selfdirected wellness. Reduces risk of flexion contracture of hip.

After 8 hours of Nursing Intervention the patient was able to: a. Cooperate with the student nurse in treatment regimen and safety measures. b. Partially participate in ADLs and desired activities such as eating, maintenance of proper hygiene.

Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities.

Provide footboard, wrist splints, trochanter/ hand rolls as appropriate.

Assist with/encourage self-care activities (e.g., bathing, shaving).

Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures.

Provide/assist with mobility by means of wheelchair, walker, crutches, and canes as soon as possible. Instruct in safe use of mobility aids.

Early mobility reduces complications of bed rest (e.g., phlebitis) and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety. Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation.

Encourage increased fluid intake to 2000–3000 ml /day (within cardiac tolerance), including acid/ash juices.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective:

Acute pain r/t inflammation and swelling.

After 8 hours of nursing intervention the patient will able to reduce the pain from level 8 to level 2 of pain.

Encourage patient to verbalize about pain. Encourage patient to do deep breathing exercises

Promotes cooperation from the client. To promote relaxation, decrease perception of pain, increase oxygen circulation. To promote relaxation and prevent fatigue. Nonpharmacological treatments promote relaxation and distract perception to pain.

After 8 hours of nursing intervention, goal met, the patient was able to reduce the pain from level 8 to level 2 of pain.

Objective:  Pain scale 8/10  Facial Grimace  Limited ROM  Slowed movement

Encourage adequate rest period Perform nonpharmacolog ical interventions such as music therapy and gentle massage Provide comfort measures such as cold compress and pillows

Comfort measures such as cold compress relieve pain and pillows reduce tension

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