Patient's name: Manuel Villafranca Jr. Diagnosis: Fx. cl. comp. Disp.

M3rd Femur R CUES NURSING DIAGNOSIS Subjective: "Medyo nahihirapan kong igalaw yung kanang paa ko." as verbalized by the patient. Objective: Guarding behavior when turning With limited ROM Needs assistance when sitting up or standing Activity intolerance related to muscle weakness due to fractured bone over the M 3rd Femur R.

Student's name: Alabin, Bernadette M. N3X - Group 2 SCIENTIFIC DESIRED NURSING EVALUATION RATIONALE OUTCOME INTERVENTION STANDAR CRITERIA D Activity Short term: INDEPENDENT intolerance occurs After my 3 days >The >After 3 because of low of nursing 1. Position patient patients days of HGB and HCT intervention, the to maintain body activity nursing level there will be patients activity alignment. Use intolerance interventio decrease oxygen intolerance will assistive devices as was n, the being delivered to be decreased. needed -- to reduced. patients the tissues of the maintain joint She was activity body since the Long term: function and able to do intolerance HGB is responsible After 30 days of prevent daily decreased for the nursing musculoskeletal activities and she oxygenation of intervention, the deformities. like oral was able the tissue. As a patients activity 2. Turn and position hygiene, to cope up compensatory will be fully at least every 2 changing with the mechanism, the recovered and hours, establish a her daily body will increase will be doing turning schedule for positioning activities. its demand of activities of daily dependent patients. on the bed oxygen by living. Post at bedside and by herself. increasing monitor frequency ->After the respiratory rate of turning helps to 30 days of the patient which prevent skin nursing results then to breakdown by interventio fatigue. Because relieving pressure. n, the of this there will 3. Asses patient's patient be fast level of functioning was fully consumption of using the functional recovered ATP leading to mobility scale. with her weaker Communicate level activity contractions thus to all staff. -intolerance causing muscle communication and she weakness. And if among staff was able the patient has members ensures to provide muscle weakness, continuity of care self care. there will be and preserves She coped

activity intolerance. Source: www.docstoc.com

identified level of independence. 4. Unless contraindicated, perform range of motion exercise every 2-4 hours. Progress from passive to active, according to patient tolerance. -- rangeof-motion exercises prevent joint contractures and muscular atrophy. 5. Teach patient how to perform isometric exercises -- to maintain and improve muscle tone and joint mobility. 6. Assist patient in carrying out selfcare, as tolerated. -to foster independence and improve mobility. 7. Encourage patient involvement in care planning and decision making -to enhance compliance. 8. Explain rationale for maintaining or improving activity level. Discuss factors that increase risk of activity

up to her daily activities

intolerance . -education will help patient avoid activity intolerance. 9. Encourage patient to carry out activities of daily living by offering emotional support and positive feedback . -- this will enhance patient's self0esteem and motivation. COLLABORATIVE 1. Involve in a regular exercise program as ordered. Exercises may include: active range-ofmotion (ROM) exercises on all unaffected joints every 4 hours isometric exercises (flexing and extending the extremity and tightening and relaxing muscles) involving the affected area every 2 to 4 hours limbstrengthening exercises,

-- Regular exercise helps maintain muscle tone and joint mobility and, if the child will need crutches, helps prepare him for crutch walking