NURSING DIAGNOSIS

INTERVENTIONS

RATIONALE

EVALUATION

Acute Pain related to Muscle spasms Movement of bone fragments, edema, and injury to the soft tissue Traction, immobility device Stress, anxiety

Perform a comprehensive assessment of pain including location, characteristics, onset/duration, frequency, quality, severity Maintain immobilization of affected part Elevate and support injured extremity Perform and supervise passive or active ROM exercises Suggest diversional activities appropriate for clients age, physical abilities, and personal preferences Administer medication s for bone fractures, as indicated.

Prevents bone displacement/extens ion of tissue injury and Relieves pain. decreases edema, and may reduce pain. maintains strength and mobility of unaffected muscles Prevents boredom, reduces muscle tension, and can increase muscle strength; may also enhance coping abilities. Reduce pain

Verbalize relief of pain. Follow prescribed pharmacologic regimen Display relaxed manner, able to participate in activities, and sleep and rest appropriately Demonstrate use of relaxation skills and diversional activities, as indicated for individual situation