ASS ASSESSMENT MENT Subjective: I cannot move my left leg
Objective: (+) Facial Grimace Limited range of motion Slowed movement Limited ability to p e r f o r m g r o s s and ne motor With cast on left leg ost!ral Instability
NURSING DIAGNOSIS Impaired physical mobility related to loss of integrity of bo ne str!ct!res
PLANNING "o " o m a i n t a i n a n d incr increa ease se strength and f!nction of a#ected part
INTERVENTION $% &ote sit!ations s!ch as fract!res
RATIONALE 4a!se it may restrict movement
'% etermine the "o "o assess f!nctional f!nctional degree of immobility in mobility relation to s!ggested scale %etermine presence of complications related to immobility (pne!monia* elimination problems* dec!bit!s) % ,ssist client reposition self on a reg!lar sched!le
-%.nco!rage ade/!ate inta0e of 1!ids2n!tritio!s foods 3%S!pport a#ected part !sing pilow
NURSING *ARE PLAN +OR +RA*TURE
"o "o assess presence presence of complications
"o "o promote optim!m optim!m level of f!nction and prevent complications It promotes well5being and ma6imi7es energy prod!ction
"o "o maintain position and f!nction and red!ce ris0 of press!re press!re !lcers
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): articipationi n ,Ls and desired activities 8aintained position of f!nction and s0in integrity as evidenced by absence of dec!bit!s !lcer 8 a i n t a i n e d and Increased strength and f!nction of a#ected part
ASSESSMEN T
NURSING DIAGNOSIS
Subjective:
,c!te ain related to movement of bone fragments and inA!ry to the soft tiss!e
I have pain on my left leg with pain scale of 92$:
PLANNING "o decrease the level of pain from pain scale of 92$: to '2$:
INTERVENTION $% ,ssess presence of pain or discomfort* noting location and characteristics* incl!ding intensity (:B $: scale)* relieving and aggravating factors
Objective: Incision on the left an0le osterior casts and bandage onleft an0le ;estless i $: 2 9:mm?g
'% .levate and s!pport inA!red e6tremity
% 8aintain immobili7ation of a#ected part by means of bed rest* cast* splint* traction as order by the physician
%.nco!rage patient to disc!ss problems related to inA!ry
!lse@$$: bpm -% erform and s!pervise active and passive ;C8 e6ercises%
3% rovide alternative comfort meas!res (massage* bac0r!b* position changes)%
RATIONALE In1!ences e#ectiveness of interventions% 8any factors* incl!ding level of an6iety* may a#ect perception of pain% &ote@ ,bsence of pain e6pression does not necessarily mean lac0 of pain romotes veno!s ret!rn* decreases edema* and may red!ce pain ;elieves pain and prevents bone displacement and e6tension of tiss!e inA!ry
?elps alleviate an6iety% atient may feel need to relive the accident e6perience 8aintains strength and mobilit y of !na#ected m!scles and facilitates resol!tion of in1ammation in inA!red tiss!es Improves general circ!lationD red!ces
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): Eerbali7ation that pain was relieved from pain scale of 92$: to '2$:
9% ,pply cold or ice pac0 rst 'B9' hr and as necessary%
,dminister analgesics as ordered
areas of local press!re and m!scle fatig!e ;ed!ces edema and hematoma formation* decreases pain sensation% &ote@ Length of application depends on degree of patient comfort and as long as the s0in is caref!lly protected% Given to red!ce pain or m!scle spasms%
ASSESSMEN T
NURSING DIAGNOSIS
PLANNING
;is0 for infection "o achieve timely related to wo!nd wo!nd healingD be s e c o n d a r y free of p!r!lent t o fract!re drainage or erythema
INTERVENTION $% &ote ris0 factor for occ!rrence of infection
'% Cbserve for locali7ed signs of infection % Stress proper hand5 hygiene by all caregivers between "herapies 2clients
RATIONALE "o assess ca!sative2contrib!ti ng factors "o assess for infected sites
, rst line defense against healthcare5 associated infections
%4hange s!rgical "o prevent infection or other wo!nd dressings* as indicated* !sing proper techni/!e for changing or disposing of contaminated materials "o promote wellness -%;eview individ!al n!tritional needs
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): &o signs of infection noted on the site and achieved timely wound healing; no presence of purulent discharge or erythema
NURSING *ARE PLAN +OR R,EUMATOID ART,RITIS
ASSESSMEN T
NURSING DIAGNOSIS
Subjective:
ist!rbed =ody Image ;elated to changes in ability to perform !s!al tas0s
I don t want to go o!tside the ho!se beca!se of my condition
Objective: 4rying .6pressions of helplessness
PLANNING "o verbali7e increased condence in ability to deal with illness* changes in lifestyle* and possible limitations%
INTERVENTION
RATIONALE
.nco!rage verbali7ation abo!t concerns of disease process* f!t!re e6pectations%
rovides opport!nity to identify fears and misconceptions and deal with them directly%
.nco!raged a balanced diet* b!t ma0e s!re the patient !nderstands that special diets wont c!re ;,% Stress the need for weight control%
Cbesity adds f!rther stress to Aoints%
,scertain how patient views self in !s!al lifestyle f!nctioning* incl!ding se6!al aspects%
,c0nowledge and accept feelings of grief* hostility* dependency%
&ote withdrawn behavior* !se of denial* or over concern with body changes%
Identifying how illness a#ects perception of self and interactions with others will determine need for f!rther intervention and co!nseling% 4onstant pain is wearing* and feelings of anger and hostility are common% ,cceptance provides feedbac0 that feelings are normal% 8ay s!ggest emotional
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): Eerbali7ation in increase in condence in ability to deal with illness and changes in lifestyle
Set limits on maladaptive behavior% ,ssist patient to identify positive behaviors that will aid in coping% ,ssist with grooming needs as necessary% Give positive reinforcement for accomplishments%
e6ha!stion or maladaptive coping methods* re/!iring more in5depth intervention or psychological s!pport% ?elps patient maintain self5 control* which enhances self5 esteem%
8aintaining appearance enhances self5 image% ,llows patient to feel good abo!t self% ;einforces positive behavior% .nhances self5condence%
ASSESSMENT Subjective: I cannot move my left hand beca!se of sti#ness
NURSING DIAGNOSIS Impaired physical mobility as evidence by Aoint sti#ness and pain ris0 for arthritis
PLANNING "o display no signs of sti# Aoints and sore Aoints
INTERVENTION $% erform physical assessment on vital signs '% ,s0 the patient to stand and record the ndings
Objective: Fatig!e* malaise* sore and sti# Aoints Inability to move e6tremities Losing of weight
% .d!cate patient to drin0 plenty of 8il0
%enco!rage to increase Fl!id inta0e
RATIONALE "o determine the level of fever% "o doc!ment the patients weight and compare it to any old record to determine if the patient has indeed lost weight 4alci!m helps fortify the patients bones and ris0 for osteoporosis% Fl!ids can help the patients 1!id balance%
-% ,dminister medications for ain "o control the relief and Fever control% patients fever and pain end!red
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): ,bility to perform activities of daily living
ASSESSMENT Subjective: Im having severe Aoint pain
Objective: G!arding2prote ctive behavior ;estlessness facial grimacing
NURSING DIAGNOSIS ,c!te pain related to distension of tiss!es by acc!m!lation of 1!id
PLANNING "o alleviate pain from a pain scale of 92$: to '2$: and appear relaxed, able to sleep/rest and participate in activities appropriately
INTERVENTION Investigate reports of pain* noting location and intensity(scale of :B$:)% &ote precipitating factors and nonverbal pain c!es% •
;ecommend2provide rm mattress or bedboard* small pillow% .levate linens with bed cradle as needed% •
Irritable S0in warm to to!ch pain scale of 9 o!t of $:
S!ggest patient ass!me position of comfort while in bed or sitting in chair% romote bedrest as indicated%
RATIONALE ?elpf!l in determining pain management needs and e#ectiveness of program •
Soft2sagging mattress* large pillows prevent maintenance of proper body alignment* placing stress on a#ected Aoints.levation of bed linens red!ces press!re on in1amed2painf!l Aoints
•
,pply ice or cold pac0s when indicated
In severe disease2ac!te e6acerbation* total bedrest may be necessary (!ntil obAective and s!bAective improvements are noted) to limit pain2inA!ry to Aoint%
,dminister medications as indicated
4old may relieve pain and swelling d!ring ac!te episodes%
Salicylates* e%g%* aspirin (,S,) (,c!prin* .cotrin* HC;prin)D
rovides s!stained heat to red!ce pain
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EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): Eerbali7ation of relief of pain from pain scale of 92$: to '2$: and able to demonstrate rela6ed body post!re and be able to sleep2rest appropriately
and improve ;C8 of a#ected Aoints
ASSESSMENT Subjective: I cannot stand !p beca!se of wea0ness all over my body
Objective: With limited ;C8 nable to amb!late =ody wea0ness noted nable to 1e6
NURSING DIAGNOSIS ,ctivity intolerance related to generali7ed wea0ness
PLANNING "o increase in activity tolerance
INTERVENTION $%,ssess presence of factors contrib!ting to fatig!e
RATIONALE "o assess factors a#ecting c!rrent sit!ation
'%,ssess if assistance is "o prevent inA!ry to needed from another patient person "o maintain m!scle %.nco!rage active strength and Aoint ;C8 e6ercises range of motion
% &ote patients report of wea0ness* fatig!e* pain and any di
Symptoms may be res!lt or contrib!te to intolerance of activity
"o baseline data and to assist patient to
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b):
atient was able to increase activity tolerance b!t still needs assistance when doing a certain tas0
and e6tend 0nees freely ecreased lower e6tremity strength
3%assess n!tritional stat!s
9%,scertain ability to stand and move abo!t and degree of assistance necessary
J% ,ssist with activities and provide2monitor clients !se of assistive devices s!ch as cr!tches* wal0er* or wheelchair K% romote wellness 5 Instr!ct client2 SC in monitoring response to activity
$:% ,ssist patient in learning and demonstrating appropriate safety meas!res .nco!rage patient to maintain positive attit!de
deal with contrib!ting factors and manage activities within individ!al limits% ,de/!ate energy reserves are re/!ired for activity "o determine c!rrent stat!s and needs associated with participation in desired activities "o protect patient from inA!ry
"o indicate the need to alter activity level
"o prevent inA!ries
"o enhance sense of well5being
NURSING *ARE PLAN +OR AMPUTATION ASSESSMENT
NURSING DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective: I cannot wal0 beca!se I dont have legs anymore
Objective: amp!tated lower e6tremities Left limb5 ,, ;ight limb5=,
Impaired physical "o independently mobility r2t loss perform activities of limbs tolerated by his present condition and demonstrate optimal independence in the !se of adaptive device (wheelchair) to increase mobility
$% ,ssess for impediments to mobility s!ch as ne!rom!sc!lar impairment* medical restrictions* prolonged bed rest* limited strength* or amp!tation of e6tremities '% ,ssess patients 0nowledge of immobility and its implications
!se of wheelchair limited range of motion slo!ched post!re di
Identifying the specic ca!se g!ides design of optimal treatment plan
atients with mobility decits are at ris0 for e#ects of immobility s!ch as s0in brea0down* m!scle wea0ness* thrombophlebitis* constipation* pne!monia* and depression
%.val!ate the safety of "o promote client the immediate safety Cbstacles environment s!ch as throw r!gs can f!rther impede ones ability to amb!late safely%
% .nco!rage and facilitate amb!lation and other ,Ls when possible% ,ssisted with each position changes s!ch as@ sitting in chair and amb!lation%
"he longer the patient remains immobile the greater the level of debilitation that will occ!r%
After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): atient was able to perform independently some of the activities tolerated by his condition s!ch as dressing* grooming* and feeding%
-% Facilitate transfer training by !sing appropriate assistance of persons or devices when transferring patients to bed* chair* or stretcher%
roper !se of wheelchairs* canes* transfer bars* and other assistance
3% ;o!tinely assess the clients sitting post!re and help reposition him into so!nd alignment as needed%
4an promote activity and red!ce danger of falls% "his indirectly improves post!re
9% ;emind client to avoid p!tting press!re on their elbows
,rms are overwor0ed d!ring prop!lsion* transfers* repositioning* !pper dressing* and th!s they are at ris0 for painf!l syndromes%
J% .nco!rage client to perform passive or active assistive ;C8 e6ercises to all e6tremities s!ch as !pper e6tremity and nec0 1e6ibility once a day* every day or as tolerated%
"he p!rpose of this 1e6ibility program is to stretch (lengthen) the m!scles in the !pper body that are tight (shortened)% .6ercise promotes increased veno!s ret!rn* prevents sti#ness* and maintains m!scle strength and end!rance%
ASSESSMENT Subjective: I am afraid of what will happen to my condition
Objective: 4rying .6pressions of helplessness
NURSING DIAGNOSIS ,n6iety related to !n0nown o!tcome of disease
PLANNING "o have red!ction in an6iety as evidenced by verbali7ations of !nderstanding regarding illness and acceptance of possible o!tcomes of disease
INTERVENTION $% ,ssess patients level of an6iety
'% ,ssess blood press!re* heart rate* and respiratory rate% % etermine how patient copes with an6iety%
Increase in =5 $3:2$:: ;;53 cpm ;estlessness
% ,c0nowledge awareness of patients an6iety%
-% ;eass!re the patient that he2she has someone or somebody to depend on% 8aintain a calm manner while interacting with client% 3% se simple lang!age and brief statements when instr!cting patient abo!t self5care
RATIONALE 8ild an6iety enhances the patients awareness and ability to identify and solve problems "hese !s!ally increase d!ring an6iety
Interviewing and assessing client helps determine the e#ectiveness of coping strategies c!rrently !sed by the patient% =eca!se a ca!se for an6iety cannot always be identied% ,c0nowledgement of the patients feelings validates the feelings and comm!nicates acceptance of those feelings% ,void false reass!rances% "o allow patient to accept and prepare for the possible o!tcome of disease% "he presence of a tr!sted person may
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): Eerbali7ation of !nderstanding regarding illness* acceptance of possible o!tcomes of disease and positive
meas!res or abo!t diagnostic proced!res and medical interventions%
NURSING *ARE PLAN +OR ORI+
be helpf!l d!ring this period
ASSESSMENT Subjective: I have pain on my operative site ain scale J2$:
Objective: t grimaces d!ring any 0ind of motion or movement of his left lower e6tremity
NURSING DIAGNOSIS ,c!te pain related to C;IF of left fem!r
PLANNING "o decrease the level of pain from J2$: to '2$: and perform passive range of motion e6ercises by the end of this shift
INTERVENTION
ts C;IF s!rgery
EVALUATION
$% ,ssess the pts pain by !sing the $: point pain rating scale / hrs or ;&
Single5 item ratings of pain intensity are valid and reliable as meas!res of pain intensity
After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b):
'% erform and s!pervise active and passive ;C8 e6ercises%
8aintains strength and mobilit y of !na#ected m!scles and facilitates resol!tion of in1ammation in inA!red tiss!es
atient able to f!lly complete passive range of motion e6ercises with assistance from the sta# by the end of this shift% atients level of pain decreased from J2$: to '2$:
% 8aintain immobili7ation of a#ected part by means of bed rest
Swelling noted =@$:29:
RATIONALE
;elieves pain and prevents bone displacement and e6tension of tiss!e inA!ry
% .nco!rage to do deep breathing e6ercise "o lessen the pain and to rela6 -% ,dminister analgesic as ordered before any acitivty
ain limits mobility and is often e6acerbated by movement
3% 8onitor I M C "o eval!ate acc!rate 1!id stat!s
ASSESSMENT
NURSING DIAGNOSIS ;is0 for infection related to postoperative incision
PLANNING To be free from any signs and symptoms related to infection
INTERVENTION
RATIONALE
EVALUATION
$% &ote ris0 factors for occ!rrence of infection in the incision
"o help the patientidentify the presentris0 factors that mayadd !p to the infection
After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b):
'%Cbserve for locali7ed sign of infection at insertion sites of invasive lines*s!rgical incisions or wo!nds
"o eval!ate if the character* presence and condition of the present infection
&o signs of infection noted
% 8a0e health teachings especially in identication of environmental ris0 factors that co!ld add !p on infection
"o help the client modify2change2avoi d some of the environmental factors present which co!ld red!ce the incidence of infection%
% , d m i n i s t e r ant ibiotics aso rdered by the physician
,ntibiotics will help 0ill and stop the proliferation and growth of the bacteria which co!ld ca!se infection
ASSESSMENT Subjective: NIm afraid of what will happen to my conditionO
Objective: Fre/!ent as0ing of condition ;estlessness ,pprehension Fatig!e 4old clammy s0in alpitation Limitation to participation in activities &ight sweats
NURSING DIAGNOSIS Fear2an6iety related to sit!ational crisis as evidenced by apprehension and restlessness
PLANNING "o be able to appear rela6ed and report an6iety is red!ced to a manageable level !se of e#ective coping mechanism and active participation in treatment regimen
INTERVENTION $% etermine what the doctor has told client and what concl!sion client has reached '% .nco!rage client to share tho!ghts and feelings
% rovide open environment in which client feels safe to disc!ss feelings or to refrain from tal0ing %8aintain fre/!ent contact with client* tal0 w2and to!ch client* as appropriate
-% ermit e6pressions of anger* fear* and despair w2o confrontation 3% .6plain client the recommended "reatment* its p!rpose* and potential side5 e#ects%
RATIONALE 4laries clients information
rovides opport!nity to e6amine realistic fears and misconceptions abo!t diagnosis rovides ass!rance client is not alone or reAected
,cceptance of feelings allows theclient to begin todeal w2 sit!ation
8aybe !sef!l in brief times to help handle feelings of an6iety
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b): atient was able to appear rela6ed and report an6iety is red!ced to a manageable level
ASSESSMENT Subjective: Objective:
NURSING DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION After 12 hour of !uri!" i!terve!tio!# "o$% &$ 'et $ '$!ifete( b):
