NCP (Ideal) Nursing Diagnosis Impaired Physical Mobility related to bed rest and fractured posterior wall of the

acetabulum

Subjective cues Objective cues

-

Di jud ko kalihok tungod aning akong bat-ang, as verbalized by client. Received lying on bed, awake With bandage on left hip Limited range of motion Slowed movement and delayed responses Decreased muscle strength

Short term Goal

Within 8 hours of nursing interventions, the client will demonstrate passive/active ROM and isometric exercises and increase intake of nutritious foods and fluids.

Long term Goal

Within two weeks of nursing interventions, the client will increase strength and functioning and be able to perform self-care activities independently.

Nursing Interventions

I: Encourage participation in diversional/recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers. R: Provides opportunity for release of energy, refocuses attention, enhances patients sense of self-control/selfworth, and aids in reducing social isolation. I: Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. R: Increases blood flow to muscles and bone to improve muscle tone I: Encourage use of isometric exercises starting with the unaffected limb. R: Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. I: Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement. R: Nutrients required for healing are rapidly depleted, often resulting in a weight loss during skeletal traction. This can have a profound effect on muscle mass, tone, and strength. I: Place in supine position periodically if possible. R: Reduces risk of flexion contracture of hip. I: Assist with/encourage self-care activities (e.g., bathing, shaving). R: Enhances patient control in situation, and promotes self-directed wellness. I: Reposition periodically and encourage coughing/deep-breathing exercises. R: Prevents/reduces incidence of skin and respiratory complications. I: Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. R: Bed rest, use of analgesics, and changes in dietary habits can slow peristalsis and produce constipation. I: Encourage increased fluid intake to 20003000 mL/day. R: Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation. I: Consult with physical/occupational therapist and/or rehabilitation specialist. R: Useful in creating individualized activity/exercise program. Nursing Diagnosis Acute Pain related to movement of bone fragments and injury to the soft tissue secondary to surgery

Subjective cues

Reports of pain

Objective cues
-

With bandage on left hip Guarding and protective behaviour Grimaced face Wincing upon movement Within 8 hours of nursing interventions, the client will verbalize relief from pain or reduced pain score.

Short term Goal Long term Goal

Within two week of nursing interventions, the client will be able to participate in self-care activities independently and sleep and rest comfortably without reports of pain.

Nursing Interventions

I: Evaluate/document reports of pain/discomfort, noting location and characteristics, including intensity (010 scale), relieving and aggravating factors. R: Influences choice of/monitors effectiveness of interventions. I: Maintain immobilization of affected part by means of bed rest. R: Relieves pain and prevents bone displacement/extension of tissue injury. I: Explain procedures before beginning them. R: Allows patient to prepare mentally for activity and to participate in controlling level of discomfort. I: Medicate before care activities. Let patient know it is important to request medication before pain becomes severe. R: Promotes muscle relaxation and enhances participation. I: Perform and supervise active/passive ROM exercises. R: Maintains strength/mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues. I: Provide alternative comfort measures, e.g., massage, position changes. R: Improves general circulation; reduces areas of local pressure and muscle fatigue. I: Provide emotional support and encourage use of stress management techniques, e.g., progressive relaxation, deep-breathing exercises, visualization/guided imagery. R: Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of the stress of traumatic injury and pain I: Identify diversional activities appropriate for patient age, physical abilities, and personal preferences. R: Prevents boredom, reduces muscle tension, and can increase muscle strength; may enhance coping abilities. I: Administer medications as prescribed. R: Given to reduce pain and/or muscle spasms. I: Investigate any reports of unusual/sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics. R: May signal developing complications; e.g., infection, tissue ischemia, compartmental syndrome.