Cues Subjective: “Hindi ako makalakad dahil dito sa paa ko” as verbalized by the patient.

Objective:  With internal fixator on the phalanges of the left foot  With cast  VS as follows T: 36.2 ˚C PR: 79 bpm RR: 25 cpm BP: 120/100 mmHg

Nursing Diagnosis Activity Intolerance related to impaired physical mobility as evidenced by fracture on the phalanges of the left foot.

Inference Blunt Injury ↓ Injury to phalanges ↓ Fracture ↓ Bleeding from damaged ends of bone and from surrounding tissue ↓ Stimulates inflammatory response ↓ Increase capillary permeability ↓ Fluid/cellular exudation ↓ Edema ↓ Pain ↓ Impaired function

Objectives Short Term Goal: After 4 hours of nursing intervention the patient will:  Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.  Use identified techniques to enhance activity tolerance.  Demonstrate a decrease in physiological signs of intolerance. Long Term Goal: After 4 days of nursing intervention the patient will :  Participate willingly in necessary/desire d activities  Report measurable increase in

Intervention >Perform active or passive ROM exercises to all extremities every 24 hours.

Rationale >These exercises foster muscle strength and tone, maintain joint mobility, and prevent contractures. >turning and repositioning prevents skin breakdown and improves breathing.

evaluation Short term: After 4 hours of nursing intervention, goal is met as evidenced by verbalizing the negative factors affecting activity tolerance and a decreased in physiological signs with the following vital signs: T: 36.2˚C PR: 75bpm RR: 20cpm BP: 120/80 mmHg Long term: After 4 days of nursing intervention, goal is met as evidenced by regaining the patient’s previous range of motion in the leg and demonstrates proper exercises for the lower

>Turn and reposition the patient every 2 hrs. establish a turning schedule for the dependent patient. Post schedule at bedside and monitor frequency. > Maintain proper body alignment at all times

>Encourage active exercise. Provide a trapeze or other assistive device whenever possible.

>Teach isometric exercises

>To avoid contractures and maintain optimal musculoskeletal balance and physiologic function. >Such devices simplify moving and turning for many patients and also allow them to strengthen some upper-body muscles.

heart rate and rhythm. Begin slowly and increase daily as tolerated. >provide emotional support and encouragement > to allow patient maintain or increase muscle tone and joint mobility >activities will help patient regain help extremities. He >involve patient in care-related planning and decision making >monitor physiologic responses to increased activity level. and blood pressure >teach caregivers to assist patient with self-care activities in a way that maximizes patient’s potential >to help improve patient’s selfconcept and motivation to perform activities of daily living >to improve compliance >to ensure they return to normal within a few minutes after exercising >place needed objects within reach >this enables caregivers to participate in patient’s care and also encourages them to support patient’s . activity tolerance Demonstrates and verbalizes proper exercise of the lower extremities and can perform activities of daily living with minimal assistance. including respirations. >have patient perform self care activities.

.>explain the importance of following prescribed medical and physical therapy regimens independence. >to encourage independence >when the patient understands his condition improves. his compliance increases.

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