CUES Subjective: Hindi ko na ginagalaw masyado kasi masakit as verbalized by the patient.

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.

Evaluation 5oal met as evidenced by demonstrating fle1ion3e1tension of e1tremities.

2monitor vital sign 24urn and reposition patient

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

Scientific Background fracture

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

immobility 2assess position of splint ring of traction device

prolonged inability in turning or changing position

mproper positioning may cause skin in8ury3breakdown

$igns and symptoms

impaired skin integrity