NURSING CARE PLAN

Name of Patient: ___TL________________________ Age: _58______ Attending Physician:____Dr. L______________________________ Pathologic fracture right hip, closed complete, transverse Ward/Bed Number:__OSW____ Impression/Diagnoses: femoral neck; fracture secondary to metastatic bone CA, breast mass stage IV

WEST VISAYAS STATE UNIVERSITY College of Nursing

Clustered Cues 11/12/10; 10:00 am

Nursing Diagnosis Impaired physical mobility Pain on right related to loss lower of integrity of extremity bone rated as 5 structures. out of 10. limited range of motion on lower extremities slowed movement inability to move purposefully within physical environment, including transfers and ambulation decreased muscle

Rationale (Scientific Basis ) Limitation of independent, purposeful physical movement of the body or of one or more extremities.

Objectives of Care/ Outcome Criteria The client will be able to maintain position of function and skin integrity as evidenced by absence of decubitus or pressure ulcers by A tumor in the Nov. 13, 2010, bone causes the 2:00 pm. normal bone tissue to react by osteolytic response (bone destruction) or osteoblastic response (bone formation). Malignant bone tumors invade and destroy adjacent bone tissues. Malignant invading bone tumors weaken the structure of the bone until it

Nursing Interventions Independent Note situations such surgery, fractures amputation etc.

Rationale (Scientific Basis) as That may or restriction movement cause in

Evaluation 11/13/10; 2:00pm Goal met. The client was able to maintain position of function and skin integrity as evidenced by absence of decubitus or pressure ulcers.

Instruct in use of side rails, For position overhead trapeze, roller pads changes/transfers Support affected body To maintain position parts/joints using pillows, of function and rolls, foot support, etc. reduce risk of pressure ulcers. Encourage adequate intake of Promotes well-being fluids/nutritious foods and maximizes energy production Review safety measures as To ensure clients individually indicated (e.g. safety. use of heating pads, locking wheelchair before transfers) Involve client and significant other in care assisting them For to learn ways of managing compliance. problems of immobility. better

Assess skin integrity. Check for signs of redness, To monitor tissue ischemia. developing pressure

endurance/ strength on lower extremities

can no longer withstand the stress of ordinary use.

sores. Assess emotional response to immobility. Encourage self care. participation in To promote independence. Monitor input record and pattern. and output nutritional Pressure sores develop quickly in patients with Keep side rails (if any) and nutritional deficit. bed in low position. To promote a safe environment. Collaborative Assist with treatment of underlying condition causing pain or dysfunction.

Reference: Doenges, et. Al., (2008) Nurses pocket guide. P..457-461 Smeltzer and Bare (2010). Brunner and Suddarths textbook of Medical-surgical nursing. P. 20682069. Students Name:_______________________________ Clinical Instructor: _____________________________

Consult physical/occupational therapist as indicated.

with To develop individual activity program and appropriate support devices.