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SAINT JOSEPH COLLEGE

Institute of Health Sciences Cavite City

NURSING CARE PLAN


NAME: Andy dela Merced AGE: 35 yrs old SEX: Male ADDRESS: Molino Cavite CLINICAL IMPRESSION: fracture closed complete displaced intertrochanteric femur (L) RELIGION: Catholic ROOM NO.:222 DATE OF ADMISSION: June 22, 2013

ASSESSMENT
Cues/Evidences
Objective: Patient demonstrates difficulty with any movement of the (L) side of the lower extremities. Patient shows any discomfort and facial grimaces when moving the affected area.

DIAGNOSIS
Pathophysiology
Trauma: Patient encounter a fall from the truck his working

PLANNING
Goal and Desired Outcome
Long term goal: after a months of recovering and fracture healing patient must regained physical mobility with lessened pain associated to healing the fractured left femur. As manifested by: Lessened difficulty in any movement within the fractured part. Lessened discomforts and lessened facial grimaces while moving.

IMPLEMENTATION
Nursing Order/Action
Apply any ordered brace mobilizing the patient.

EVALUATION

Nursing Diagnosis
Impaired Physical mobility r/t acute pain s/t fractured left femur. As manifested by: Difficulty with any movement on the affected area By having discomforts and facial grimaces while moving.

Rationale for Action


Brace support and stabilize a body part allowing increased mobility. Providing unnecessary assistance promote may dependence

Increased independence in ADL.

Injury to the femur: fracture closed complete displaced intertrochanteric left femur.

and loss of functioning. Assess the patients pain by using as a pain scale as 10 being the highest and 0 as being the lowest. Position patient so that pull is Pain may limits the

Restricted or loss of function of the affected area.

patients mobility and is often exacerbated by movement. Promotes bone

Tissue swelling, bruising, hematoma, mass at the site of injury.

appropriate of the bone.

alignment and reduce risk of complications.

maintained on the long axis

Collaborative: Breakage in the skin Review follow up/ serial xrays. Shock Provides evidence callus healing Bleeding from the damage ends of bone and from surrounding tissue. of visual proper and to of

alignment or beginning formation process level

determined

activity and need for changes in additional therapy.

Inc. diameter of thigh d/t continuous blood loss.

Initiate electrical used.

or

maintain if

Maybe presence

indicated of

to

stimulation

promote bone growth in delayed healing or non union.

Hyper/hypo tension occurs to response of acute pain or loss of blood

Tachycardia <stress response)

Fatigue weakness (affected area)

Immobility or impaired gait.

Fracture of the Femur