Professional Documents
Culture Documents
Objective: Limited movement Difficulty in changing position while lying on bed With balanced skeletal traction in right leg nability to perform !DL"s #$ taken as% &&%'(cpm )&% *+bpm shows guarding behavior irritable at times
Nursing Diagnosis mpaired )hysical ,obility related to musculoskeletal impairment as evidenced by verbalization of limited range of motion.
Objectives !fter -. minutes of rendering nursing interventions and health teachings/ the patient will demonstrate behaviors that enable resumption of activities such as active and passive &0, e1ercise.
Nursing Interventions Independent: 2assist patient to do active3passive &0, e1ercise to affected and unaffected e1tremities 2observe movement of the client 2assist client or encourage client to do self care activities like bathing
Rationale 4o increase the blood flow to muscles and bone to improve muscle tone 4o note any incongruence with report of abilities 4o improve muscle strength circulation and promote self directed wellness t serves as a baseline data 4o optimize circulation to all tissues and prevent bedsores.
CUES Subjective: ,asakit daw dun sa 6ilagyan ng steinmann pin as verbalized by the nephew. Objective: With steinmann pin at right distal femur Difficulty in changing position while lying on bed With balanced skeletal traction #$ taken as% &&%'-cpm )&% *.bpm
Objectives !fter -. minutes of rendering nursing interventions and health teachings/ the patient will identify independent management and prevention of further skin infection.
Nursing Interventions Independent: 2e1amine the skin for open wound/ rashes bleeding or discoloration 2remove e1cess clothing especially the rough ones 2give bed bath 2reposition fre7uently
Rationale )rovide information regarding skin circulation and problems that may re7uire further medical intervention 4his would lead to further damage of the skin 4o promote good hygiene Lessens constant pressure on same area and minimizes for skin breakdown
Evaluation 5oal ,et. !fter -. minutes of nursing intervention the patient was able to identify management and prevention of further skin infection.
pain
body weakness