NCP (Actual) Nursing Diagnosis Impaired Physical Mobility related to loss of bone integrity of the distal third left

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Subjective cues Objective cues

Maglisod ko paglihok-lihok tungod lage aning akong paa, as verbalized by client. Received lying supine on bed Conscious and coherent With skeletal traction at left leg Limited range of motion noted Slowed movement and delayed responses observed Decreased muscle strength noted

Goal

The client will verbalize and demonstrate understanding of the situation and individual treatment and regimen and safety measures.

Nursing Interventions

I: Encourage participation in diversional/recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers. R: Provides opportunity for release of energy, refocuses attention, enhances patients sense of self-control/selfworth, and aids in reducing social isolation. I: Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. R: Increases blood flow to muscles and bone to improve muscle tone I: Provide/assist with mobility by means of wheelchair, walker, crutches, canes as soon as possible. R: Early mobility reduces complications of bed rest (e.g., phlebitis) and promotes healing and normalization of organ function. I: Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement. R: Nutrients required for healing are rapidly depleted, often resulting in a weight loss during skeletal traction. This can have a profound effect on muscle mass, tone, and strength. I: Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures. R: Reduces risk of flexion contracture of hip. I: Instruct in/encourage use of trapeze and post position for lower limb fractures. R: Facilitates movement during hygiene/skin care and linen changes; reduces discomfort of remaining flat in bed. I: Assist with/encourage self-care activities (e.g., bathing, shaving). R: Enhances patient control in situation, and promotes self-directed wellness. I: Reposition periodically and encourage coughing/deep-breathing exercises. R: Prevents/reduces incidence of skin and respiratory complications. I: Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. R: Bed rest, use of analgesics, and changes in dietary habits can slow peristalsis and produce constipation. I: Encourage increased fluid intake to 20003000 mL/day. R: Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation. Nursing Diagnosis Risk for Injury related to altered mobility and episodes of muscular spasms

Subjective cues

Di ko kalihok kaayo ug tarong tungod sa piang sa akong paa nya magkurog pa jud ko usahay, as verbalized by client.

Objective cues
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Received lying supine in bed Conscious and coherent With skeletal traction at left leg Limited range of motion Slowed movement and delayed responses observed Episodes of chills noted

Goal

The client will verbalize understanding of individual factors that contribute to possibility of injury and be free from injury.

Nursing Interventions
I: R: I: R: I: R: I: R: I: R: I: R: I: R: I: R: I: R: I: R:

Assess clients muscle strength, gross and fine motor coordination. To identify risk for falls Provide healthcare within a culture of safety. To prevent errors resulting in client injury Instruct client/SO to request assistance as needed. To avoid injury during physical activities Monitor environment for potential unsafe condition. To make modifications as necessary Raise side rails and put pillows on the patients side Reduce the risk for falls Encourage turning to sides every two hours Prevent decubital ulcer Reposition periodically and encourage coughing/deep-breathing exercises. Prevents/reduces incidence of skin and respiratory complications (e.g., decubitus, atelectasis, pneumonia). Instruct in safe use of mobility aids. Learning the correct way to use aids is important to maintain optimal mobility and patient safety. Consume a calcium rich diet from a combination of foods and supplements. To decrease bone fragility and prevent further injury. Provide footboard, wrist splints, trochanter/hand rolls as appropriate. Useful in maintaining functional position of extremities, hands/feet, and preventing complications (e.g., contractures/footdrop).