Nursing Diagnosis: Impaired Physical Mobility

Assessment Planning Intervention Rationale Evaluation

Subjective At the end of the Independent: At the end of the
Data: nurse-client 1.Assess the 1.Patient may nurse- Client
interaction, the degree of be restricted interaction, the
Objective patient will be immobility by self-view goals were:
Data: able to: produced by or self-
-presence of injury or perception a. Partially met.
limb a.regain mobility treatment and out of patient has
immobilization at the highest note patient’s proportion regained
(cast) possible level perception of with actual some
BP- 130/60 immobility physical mobility.
mmHg b. maintain limitations, b. fully Med.
HR- 65 bpm position of requiring patient able
RR- 18 cpm function Information to maintain
T- 36.8 C or position of
c. increase intervention function
strength/function to promote c. . fully met
of affected and progress patient has
compensatory towards increasing
body parts wellness. strength of
2. Encourage 2. Provides affected body
d. demonstrate participation in opportunity part.
techniques that diversional for release of d. . fully met
enable activities. energy, re patient
resumption of focuses demonstrated
activities attention and techniques to
enhances enable
sense of self resumption of
control and activities
self worth.
3. Teach patient 3. Increases
or assist with blood flow to
active and muscles and
passive ROM bone to
exercises of improve
affected and muscle tone,,
unaffected preserve joint
extremities mobility
prevent
contractures
and atrophy.

4. Provide wrist 4. Useful in

splints, hand maintaining a
roll as functional
appropriate position of
extremities
 and prevent
complications.
5. Assist with 5. Promote
self care self-directed
activities such wellness and
as bathing, enhances
dressing patient’s
control in the
situation.
6. Reposition 6. Prevent or
periodically and reduces the
encourage incident says
coughing and of skin and
deep breathing respiratory
exercises. complications.

7. Teach patient 7. Effective

and significant pain
other in the use intervention
of analgesics will enhance
and exercises patient’s
instruct non ability to
pharmacologica engage in
l pain appropriate
management. activity to
exercise.

Nursing Diagnosis: Risk for infection related to fracture and traumatized tissues
Assessment planning intervention rationale
Subjective data: At the end of the nurse- Independent:
client interaction, The 1.Inspect The skin for pre- 1. Pins or wires sh
Objective Data: patient will be able to: existing irritation or breaks in not be inserted
Presence of restricting device a. Achieve timely continuity. through skin
BP- 130/60 mmHg wound healing infections, rash
HR- 65 bpm b. Free from any signs abrasions.
RR- 18 cpm of infection such as 2. , Assess being sites, and 2. May indicate th
T- 36.8 C fever skin areas noting reports of onset of local
increased pain, burning infection or tiss
sensation, presence of necrosis.
edema, erythema or
drainage.
3. Instruct patient not to
touch the insertion sites 3. Minimize
4. . Monitor vital signs note opportunity for
presence of chills, fever, contamination
malaise, Changes in 4. Hypotension,
mentation. confusion,
tachycardia, ch
5. Provide sterile pin or favor reflect
wound care, a clean developing sep
environment according to 5. may prevent cr
protocol and exercise contamination
meticulous hand washing. possibility of
infection.
Collaborative:
6. Administered medications
as indicated, antibiotics such
as Cefuroxime, Ceftriaxone. 6. Antibiotics may
use prophylacti
or maybe geare
toward a specifi
microorganism