Assessment Nursing Planning Implementation

Scientific Rationale Evaluation

Diagnosis
 Assess patient’s
 Provides basis for
 Verbalization Deficient After 8 hours of knowledge of
teaching and After 8 hours of
of the problem Knowledge and nursing disease, diet,
techniques to nursing
and request Osteoporotic intervention, the medication, and
promote intervention, the
for information process and patient will be exercise program to
compliance. patient was able to
 Fear of further treatment able to: arrest progression
of Disease is not accurately verbalize
bone loss and regimen bone deterioration.
usually detected understanding of
fractures  Achieve
until 24-40% of medications and
 Presence of increased
calcium in bone is methods of
preventable knowledge
lost. administration and
complication and  Assess the patient’s
 Most individuals patient exhibits no
compliance understanding of
with osteoporosis injury, fall, or
with medical osteoporosis.
are not diagnosed trauma that may
regimen to
until an acute predispose to a
minimize
fracture occurs. fracture.
bone  Assist to plan
 Exercise will
demineralizat exercise program
strengthen bone.
ion and according to
injury. capabilities.
 Compliant  Teach patient about
 Adequate calcium
with nutrition and
calcium helps to prevent
medication intake.
osteoporosis.
and dietary  Instruct patient in
 Prevents injury that
instructions. methods to perform
can occur with
 Perform daily activities of daily
osteoporosis with
exercises living and to avoid
minimal trauma.
within lifting, bending, or
identified carrying heavy
limitations objects.
and to
prevent
further bone
loss or
deterioration.
 Assessment Nursing Planning Implementation
Scientific Rationale Evaluation
Diagnosis

 Reports of Acute Pain After 8 hours of  Maintain

 Relieves pain and After 8 hours of
pain related to nursing immobilization of
prevents bone nursing
 Distraction; Fracture and intervention, the affected part by
displacement and intervention, the
self- muscle spasm patient will be means of bed rest,
extension of tissue patient was able to
focusing/narro able to: cast, splint,
traction. injury. verbalize decrease
wed focus;  Elevate bed covers;
 Maintains body pain intensity and
facial mask of  Verbalize keep linens off toes.
warmth without demonstrate use of
pain relief of pain.
discomfort. relaxation
 Guarding,  Display  Evaluate and
 Absence of pain techniques and
protective relaxed document reports of
expression does understanding of
behavior; manner; able pain or discomfort,
not necessarily the importance of
alteration in to participate noting location and
mean lack of pain. non-pharmacologic
muscle tone; in activities, characteristics,
nursing pain
autonomic sleep/rest including intensity
management.
responses appropriately (0–10 scale),
. relieving and
 Demonstrate aggravating factors.
use of  Provide alternative
 Improves general
relaxation comfort measures
circulation; reduces
skills and (massage, backrub,
areas of local
diversional position changes).
pressure and
activities as
muscle fatigue.
indicated for  Administer
 Given to reduce
individual medications as
pain or muscle
situation. prescribed by the
spasms.
physician.
 Provide emotional
 Refocuses
support and
attention, promotes
encourage use of
sense of control,
 stress management
and may enhance
techniques.
coping abilities.
 Assessment Nursing Diagnosis Planning
Implementation Scientific Rationale Evaluation

Risk Factors: Risk for Injury: After 8 hours of  Assess

general  This is to After 8 hours of
 Malnutrition Fracture related to nursing status of
the determine the nursing
 Physical (e.g., osteoporotic bone intervention, the patient.
patient’s intervention, the
broken skin, patient will be able
condition that patient was able
altered mobility) to:
may cause to verbalize
 Biochemical,
injury. different
regulatory  Be free from  Avoid use
of  If patients are measures on how
function (e.g., injuries. restraints.
Obtain a restrained, they to prevent injury
sensory  Explain physician’s
order if can sustain and the patient
dysfunction, methods to restraints
are injuries. was free from any
integrative prevent injury. needed.
injuries.
dysfunction,  Identify factors  Provide
medical  Signs are vital
effector that increase
identification for patients at
dysfunction, risk for injury. bracelet
for risk for injury.
tissue hypoxia)  Relate intent to patients at
risk for
 Decreased hem practice injury.
oglobin selected  Ask family
or  This is to
 Developmental prevention significant
others prevent the
age measures. to be with
the patient from
(physiological,  Increase daily patient to
prevent accidentally
psychosocial) activity, if him or her
from falling or pulling
feasible.
accidentally falling out tubes.
or pulling
out
tubes.
 Aid
patients sit in a  Patients are
stable
chair with likely to fall when
armrests.
left in a

wheelchair.
 Use
culturally  To prevent
 relevant
injury occurrence of
prevention
injury.
programs
whenever
possible.
 Assessment Nursing Planning Implementation
Scientific Rationale Evaluation
Diagnosis

 Inability to Impaired After 8 hours of  Assess

patient’s  Identifies problems After 8 hours of
move Physical Mobility nursing functional
ability for and helps to nursing
purposefully related to bone intervention, the mobility and
note establish a plan of intervention, the
within loss as patient will be able changes.
care. patient was able
physical evidenced by to:  Provide range
of  Helps to prevent to receive
environment, spontaneous motion
exercises joint contractures assistance from
including bed fracture  Maintain every shift.
and muscle atrophy. the family and the
mobility, functional  Reposition
patient  Turning at regular nurse in
transfers, mobility as every 2 hours
and intervals prevents performing ADLs
and long as prn.
skin breakdown and patient was
ambulation possible within
from pressure able to perform
 Inability to limitations of
injury. activities to
perform disease  Apply
trochanter rolls  Prevents maintain
action as process. and/or pillows
to musculoskeletal functional mobility.
instructed  Have a few, if maintain joint
deformities.
 Limited ROM any, alignment.
 Reluctance complications  Avoid
restraints as  Inactivity created by
to attempt related to possible.
the use of restraints
movement immobility as
may increase
disease
muscle weakness
condition
and poor balance.
progresses.  Encourage
 Provides
participation
in opportunity for
diversional or
release of energy,
recreational
activities. refocuses attention.
 Instruct family
 Prevents
regarding ROM
complications of
exercises,
methods immobility and
 of transferring
knowledge assists
patients from
bed to family members to
wheelchair, and
be better prepared
turning at
routine for home care.
intervals.
 Assessment Nursing Planning Implementation
Scientific Rationale Evaluation
Diagnosis

 Deformity Imbalanced After 8 hours of  Instruct

 Vitamin D aids in After 8 hours of
 Kyphosis Nutrition related nursing recommended daily
absorption of nursing
 Loss of to inadequate intervention, the intake for
calcium. calcium and intervention, the
height Calcium and patient will be able
improves muscle patient was able
 Fractures Vitamin D to:
strength. to verbalize
 Low Calcium  Present  Instruct on the
 The patient should different ways on
level understanding importance of
be outside 15 how to have
of significance adequate exposure
minutes daily. proper selection of
of nutrition to to sunlight to
prevent foods that is
healing vitamin D
deficiency. needed for her
process and  Instruct patient
to  Exercise can help condition.
general health. perform gentle
build strong bones
 Verbalize and exercises.
and slow bone loss.
demonstrates  Provide a
balanced  A diet high in
selection of diet.
nutrients that
foods or meals
support skeletal
that will
metabolism: vitamin
accomplish a
D, calcium, and
termination of
protein.
weight loss.  Limit alcohol
intake.  Alcohol may
 Demonstrate
decrease bone
behaviors,
formation and
lifestyle
reduce the body’s
changes to
ability to absorb
recover and/or
calcium.
keep  Take a
nutritional  It may provide more
appropriate history with the
accurate details on
 weight. participation of
the patient’s eating
significant
others. habits.