COLLEGE OF NURSING

SILLIMAN UNIVERSITY DUMAGUETY CITY

CUES/EVIDENCES
Subjective: Verbalized hesitancy to move because of pain. Rates pain felt on right knee as 7 on a scale of 0-10, 10 being the highest pain felt and 0 as no pain felt. Objective: Vital signs: T= 37 C PR= 80 bpm RR= 26 cpm BP= 130/80 mmHg Limited range of motion. Limited ability to perform gross or fine motor skill. Difficulty in turning. Slowed movements.

NURSING DIAGNOSIS
Impaired physical mobility related to pain.

OBJECTIVES
Within our two day nursing care, the patient will: a. Maintain normal vital signs. b. Verbalize understanding of situation and individual treatment regimen and safety measures. c. Demonstrate techniques or behaviors that enable resumption of activities. d. Maintain increased strength of affected body part. e. Maintain or increase function in affected part. f. Verbalize the importance of proper

INTERVENTIONS
Continuously evaluate and monitor changes in the degree of joint pain.

RATIONALE
Level of activity depends on progression and resolution of inflammatory process. To note any incongruencies with reports of abilities. Feelings of frustration or powerlessness may impede attainment of goals. Systemic rest during acute attacks is important in order to reduce fatigue and improve strength.

EVALUATION
a. Goal met. Client was able to maintain normal vital signs. b. Goal met. Client was able to verbalize understanding of situation and individual treatment regimen and safety measures. c. Goal met. Client Demonstrated techniques or behaviors that enable resumption of activities. d. Goal met. Client was able to maintain increased strength of

Observe movement when client is unaware of observations. Note emotional/behavio ral responses to problems of inability.

Shows short breath upon exertion.

Occasionally drinks alcoholic beverages. Decreased muscle strength. Presence of Arthritis (Gouty) on right knee: Uric acid result

Maintain bed rest or chair rest.

:9.0mg/dl (high) Shows signs of reluctance to move.

positioning. g. Maintain position function and skin integrity as evidenced by absence of contractures, foot drop, decubitus and so forth.

Encourage adequate fluid intake.

Assist with excretion of uric acid and decrease likelihood of stone formation. Maintains or improves joint function, muscle strength and general stamina. Maximizes joint function and maintains mobility.

Assist in active and passive motions.

Encourage patient to maintain upright and erect posture, when sitting, standing and walking. Encourage patient to avoid or minimize alcohol intake. Encourage intake of foods rich in purines like shell fish and sardines. Provide safety measures and needs. Administer antiinflammatory drugs as

That can precipitate an acute attack.

Avoid foods that can precipitate and attack.

Help prevent accidental injuries or falls. Relieves pain and swelling.

affected body part. e. Goal met. Client was able to maintain increased function on affected part. f. Goal met. Client was able to verbalize the importance of proper positioning in order to help alleviate the pain felt on the leg. h. Goal met. Client was able to maintain position function and skin integrity as evidenced by absence of contractures, foot drop, decubitus and so forth.

prescribed by physician.