CUES

NURSING DIAGNOSIS Impaired physical mobility, inability to stand alone related to skeletal impairment to facture of the left femor

RATIONALE

GOAL & OUTCOME CRITERIA After 8 hours of rendering appropriate nursing interventions the patient will be able to: 1. Demonstrate increasing function of the extremities. Regain or maintain mobility at the highest possible level. Verbalize understanding of the situation /risk factors, individual therapeutic regimen and safety measures.

NURSING ACTIONS & NURSING ORDERS Independent - assist patient to do active ROM exercises on the lower extremities.

RATIONALE

EVALUATION

Subjective cues: - masakit ung bewang at paa ko as verbalized by the patient. Objective - grimace face noted - limited ROM -v/s BP: 130/80 mmHg T: 38.2C P : 75 bpm R : 20 cpm

(Gulanick & Myers: 2007, p. 126)al neck

Fractures occur when the bone is subjected to stress greater that it can absorb. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joints dislocations, ruptured ten-dons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that caused the fracture fragments. After a fracture, the extremities cannot function properly because normal functions of muscle depend on the integrity of the bones which they are attached.

-to improve muscle strength and joint mobility.

After 8 hours of rendering appropriate nursing interventions the patient was able: 1.Demonstrate increasing function of the extremities.

2.

Dependent -administer analgesics such as Tramadol (Tramal) as prescribed by the physician.

-in order for the muscle to be more relax and relieves the pain

2.Regain or maintain mobility at the highest possible level. 3. Verbalize understanding of the situation /risk factors, individual therapeutic regimen and safety. -Goal was met

3.

Collaborative - consult with physical or occupational therapist as indicated.

Independent -assess degree of mobility produced by injury or treatment and note patients perception of immobility.

-to develop individual exercise or mobility program and identify appropriate adjunctive devices. -patient may be restricted by selfview or selfperception out of proportion with actual physical limitations requiring interventions to promote progress toward wellness.

(GULANICK & MYERS: 2007,

p. 127)

Bondoc, Maricris Dianne D.

BSNIII-B4

CB-13