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>Apply cold pack first >Reduces edema and hematoma
24-72 hours and as formation, decreases pain
necessary. sensation.
Subjective: P-Impaired physical Vehicular accident After 4 hours of >Asses degree of >Client may be restricted by self- Goal PARTIALLY MET
mobility ralted to pain rendering appropriate immobility produced by percepltion out of proportion wit as Evidenced by:
“Nahihirapan na nga and discomfort and nursing interventions, injury/treatment and actual physical limitations
ako, gusto ko nang physiologic immobility the client will improve note client’s perception requiring interventions to The patient identify
maglakad” E-Pain and discomfort muscle strength and of immobility. promote progress toward some ways in improving
As verbalized by the and physiologic do some range of wellness. muscle strength and
patient immobilty Strong force causes motions on the >Encourage >Provides opporunity for release done some range of
S-As evidenced By: femoral fracture and extremities to prevent participation in of energy, refocuses attention, motions on the
muscle spasm atrophy and will diversional/recreational enhances client’s sense of control extremities and
>Inability to move >Inability to move demonstrate actvities. Maintain and aids in reducing social demonstrated some
purposefully purposefully techniques that enable stimulating isolation. techniques that enable
>Reluctant to move >Reluctant to move resumption of environment; e.g., radio, resumption of activities
freely freely Damage bone nerve activities of daily TV, newspapers, of dailyliving.
>Limited ROM >Limited ROM ending living personal
>Decreased muscle >Decreased muscle possesions/pictures,
strength and control strength and control clock Calendar visits,
>Unable to walk. >Unable to walk. Impaired Physical from family/friends.
>With fair skin. >With fair skin. Immobilty
>With Steinmann pin >With Steinmann pin >Instruct client in/assist >Increases blood flow to muscles
inserted at proximal inserted at distal 3rd of with active/passive and bone to improve mescle tone
3rd of the femur(BST) the femur(BST) ROM exercises of and maintain joint mobility,
>No signs of swelling >No signs of swelling at affected and unaffected prevent contractures and atrophy
at Steinmann pin site Steinmann pin site extrimities. and calsium resorption from
>Needs assistance in >Needs assistance in disuse.
doing ADL’s. doing ADL’s.
>Enourage of isometric >Isometrics contract muscles
exercises starting with without bending joints or moving
the unaffected limb. limbs and help maintain muscle
strength and mass.
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