CUES Subjective: Sumasakit lang minsan pero nakakaya ko naman, pero noong una sobrang sakit talaga as verbalized

by the patient Objective: Limited range of motion Inability to purposely move within the environme nt Decreased muscle strength

NURSING DIAGNOSIS Problem: Impaired Physical Mobility Etiology: r/t pain secondary to immobilization Signs & Symptoms: Limited range of motion Inability to purposely move within the environme nt Decreased muscle strength

SCIENTIFIC BACKGROUND Trauma

GOALS & OBJECTIVES

Goal: After, the patient will regain and Tissue destruction maintain mobility at and bone fracture the highest possible level Inflammation and swelling in the area Objectives: Maintain position of function Increase strength and function of affected and compensatory body parts Demonstrate techniques that enable resumption of activities, especially ADL Verbalize understanding of the situation and individual treatment regimen and safety measures

NURSING INERVENTIONS Independent: 1. Assess degree of immobility produced by injury and treatment and note clients perception of immobility 2. Encourage participation in diversional activities. Maintain a stimulating environment 3. Instruct client in active, or assist with passive ROM exercises of affected and unaffected extremities 4. Encourage use of isometric exercises, starting with the unaffected limb 5. Provide footboard and trochanter as appropriate 6. Place in supine position periodically if possible when

RATIONALE

EVALUATION

1. Client may be Level of restricted by self- Attainment: view out of proportion with actual physical Evidences: limitations, requiring information and interventions to promote progress toward wellness 2. Provides opportunity for release of energy, refocuses attention, enhances clients sense of selfcontrol and selfworth, and aids in reducing social isolation 3. Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse

Muscle spasms and pain in the area Decreased muscle strength

Limited movement as a compensatory mechanism to avoid pain

4. Isometrics contract muscles without bending joints or moving 7. Assist with and limbs and help encourage self-care maintain muscle activities such as strength and bathing, shaving mass and oral hygiene 5. Useful in 8. Monitor BP with maintaining resumption of functional activity. Note position of reports of dizziness extremities and preventing 9. Reposition complications periodically and encourage 6. Reduce risk of coughing and deep flexion breathing exercises contracture of hip 10. Encourage increased fluid 7. Improves muscle intake of 2-3L/day strength and within cardiac circulation, tolerance enhances client control in 11. Provide diet high situation, and in proteins, promotes selfcarbohydrates, directed wellness vitamins, minerals 8. Postural 12. Increase the hypotension is a amount of fiber in common the diet. Limit gasproblem forming foods following prolonged Dependent: bedrest 1. Consult with physical or 9. Prevents

traction is used to stabilize lower limb fractures

occupational therapist or rehabilitation therapist 2. Refer to dietician or nutrition team, as indicated 3. Initiate bowel program stool softeners , enema or laxatives as indicated 4. Refer to psychiatric clinical nurse specialist or therapist as indicated

incidence of skin and respiratory complications 10. Keeps the body well hydrated, decreasing risk of urinary infection and stone formation, and helps to prevent constipation 11. For rapid healing 12. Adding bulk to stool helps prevent constipation. Gas-forming foods may cause abdominal distention 1. Useful in creating aggressive individualize d activity or exercise program 2. Client with fractures may have special consideration s

3. Important to promote regular bowel evacuation and prevent constipation 4. Client may require more intensive treatment to deal with reality of current condition

CUES Subjective: Sumasakit lang minsan pero nakakaya ko naman, pero noong una sobrang sakit talaga as verbalized by the patient Objective: Pain scale of 5/10 Narrowed focus Alternatio n in muscle tone Limited range of motion

NURSING DIAGNOSIS Problem: Acute Pain Etiology: r/t presence of immobility device secondary to physical injury of the soft tissues and nerve trauma Signs & Symptoms: Pain scale of 5/10 Narrowed focus Alternatio n in muscle tone

SCIENTIFIC BACKGROUND Trauma

GOALS & OBJECTIVES

Goal: After, the Tissue destruction patient will verbalize and bone fracture relief of pain Objectives: Display relaxed manner, able to participate in activities, and sleep and rest appropriately Demonstrate use of relaxation skills and diversional activities

NURSING INERVENTIONS Independent: 1. Maintain immobilization of affected part by means of bed rest. 2.Elevate and support injured extremity

RATIONALE

EVALUATION

1.Relieves pain and prevents bone Level of displacement/extensi Attainment: on of tissue injury 2.Promotes venous return, decreases edema, and may reduce pain 3.Can increase discomfort by enhancing heat production in the drying cast 4.Maintains body warmth due to pressure of bed linens on affected parts 5.Influences choice of, and monitors effectiveness of interventions Evidences:

Inflammation and swelling in the area

Disruption of blood supply, vasoconstriction and destruction of marrow in the bone

3.Avoid use of plastic sheets/pillows under the limbs 4.Elevate bed covers and keep linens off toes 5. Evaluate and document reports of pain or discomfort, noting location and characteristics. Note nonverbal pain cues, such as changes in vital signs and behaviors 6.Encourage client to discuss problems related to injury 7.Perform and supervise passive or active ROM exercises 8.Provide alternative comfort measures

Irritation of nerve endings and stimulation of pain receptors

PAIN

6.Helps alleviate anxiety 7. Maintains strength and mobility of

(massage, backrub or position changes) 9.Provide emotional support and encourage use of stress management techniques (DBE, guided imagery, therapeutic touch. Dependent: 1.Administer medications, as indicated 2.Maintain continuous IV. Maintain safe and effective infusions and equipment

unaffected muscles and facilitates resolution of inflammation I injured tissues. 8.Improves general circulation; reduces areas of local pressure and muscle fatigue 9.Promotes sense of control and may enhance coping abilities in the management of the stress of traumatic injury and pain 1.Given to reduce pain and muscle spasms 2.Permit early mobilization and physical therapy