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Subjective cues Objective cues
“Di jud ko kalihok tungod aning akong bat-ang,” as verbalized by client. Received lying on bed, awake With bandage on left hip Limited range of motion Slowed movement and delayed responses Decreased muscle strength
Short term Goal
Within 8 hours of nursing interventions, the client will demonstrate passive/active ROM and isometric exercises and increase intake of nutritious foods and fluids.
Long term Goal
Within two weeks of nursing interventions, the client will increase strength and functioning and be able to perform self-care activities independently.
I: Encourage participation in diversional/recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers. R: Provides opportunity for release of energy, refocuses attention, enhances patient’s sense of self-control/selfworth, and aids in reducing social isolation. I: Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. R: Increases blood flow to muscles and bone to improve muscle tone I: Encourage use of isometric exercises starting with the unaffected limb. R: Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. I: Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement. R: Nutrients required for healing are rapidly depleted, often resulting in a weight loss during skeletal traction. This can have a profound effect on muscle mass, tone, and strength. I: Place in supine position periodically if possible. R: Reduces risk of flexion contracture of hip. I: Assist with/encourage self-care activities (e.g., bathing, shaving). R: Enhances patient control in situation, and promotes self-directed wellness. I: Reposition periodically and encourage coughing/deep-breathing exercises. R: Prevents/reduces incidence of skin and respiratory complications. I: Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. R: Bed rest, use of analgesics, and changes in dietary habits can slow peristalsis and produce constipation. I: Encourage increased fluid intake to 2000–3000 mL/day. R: Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation. I: Consult with physical/occupational therapist and/or rehabilitation specialist. R: Useful in creating individualized activity/exercise program. Nursing Diagnosis Acute Pain related to movement of bone fragments and injury to the soft tissue secondary to surgery
. Short term Goal Long term Goal Within two week of nursing interventions. I: Provide emotional support and encourage use of stress management techniques. and can increase muscle strength. reduces areas of local pressure and muscle fatigue. R: Promotes muscle relaxation and enhances participation. . R: Refocuses attention. R: Improves general circulation. promotes sense of control. Let patient know it is important to request medication before pain becomes severe. and poorly localized pain unrelieved by analgesics. R: Given to reduce pain and/or muscle spasms.g. I: Provide alternative comfort measures. relieving and aggravating factors. e. e. visualization/guided imagery. the client will verbalize relief from pain or reduced pain score.. the client will be able to participate in self-care activities independently and sleep and rest comfortably without reports of pain. I: Administer medications as prescribed. progressive. tissue ischemia. progressive relaxation. massage. physical abilities. position changes. and personal preferences. e. and may enhance coping abilities in the management of the stress of traumatic injury and pain I: Identify diversional activities appropriate for patient age. R: Maintains strength/mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues. I: Explain procedures before beginning them. I: Medicate before care activities. R: Allows patient to prepare mentally for activity and to participate in controlling level of discomfort. R: Influences choice of/monitors effectiveness of interventions. reduces muscle tension. infection.Reports of pain Objective cues - With bandage on left hip Guarding and protective behaviour Grimaced face Wincing upon movement Within 8 hours of nursing interventions. R: Relieves pain and prevents bone displacement/extension of tissue injury. deep-breathing exercises. noting location and characteristics. I: Investigate any reports of unusual/sudden pain or deep. Nursing Interventions I: Evaluate/document reports of pain/discomfort.g. may enhance coping abilities.. compartmental syndrome.g. I: Perform and supervise active/passive ROM exercises. R: Prevents boredom. including intensity (0–10 scale). R: May signal developing complications. I: Maintain immobilization of affected part by means of bed rest.