Assessment

Subjective – "Hindi ako masyado makagalaw dahil dito sa ikinabit sa paa ko," as verbalized by the patient.

Objective – limited ROM

Nursing Diagnosis

Impaired physical mobility r/t restrictive therapy amb inability to move purposefully and limited ROM

Analysis

Restrictive therapies such as application of tractions, casts, and braces are used to immobilize the fractured bones to facilitate bone union. However, these devices pose a limitation to the mobility of the individual.

Objective

At the end of the shift, the patient will be able to regain mobility in an allowable level.

1. The patient will be able to increase strength of affected and compensatory body parts within 2 days.

2. The patient will be able to demonstrate Active ROM exercises after sample demonstrations of the said exercises.

3. The patient will be able to do self-care activities immediately after the intervention

Nursing Intervention

1. Assess degree of immobility produced by treatment and note patient’s perception of immobility.

2. Instruct patient with active ROM exercises of affected and unaffected extremities such as flexion and dorsiflexion of the toes of the affected leg, and flexion and extension of the unaffected leg.

3. Instruct in use of the overhead trapeze.

4. Encourage self-care activities such as bathing and oral care.

Rationale

> Patient may be restricted by self- perception out of proportion with actual physical limitations.

> Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility, and prevent contractures or atrophy.

> Facilitates movement during hygiene/skin care and linen changes.

> Improves muscle strength and circulation, enhances patient control in situation, and promotes self-directed wellness

Evaluation

Goal met: The patient was able to regain mobility that her condition allowed.

Goal met: The patient showed increased strength in her affected and unaffected legs as showed by her independence in performing active ROM exercises.

Goal met: The patient was able to do a return demonstration of the active ROM exercises taught to her.

Goal met: The patient was able to resume with her self-care activities.

I will feature sample Case Studies and Drug Studies in the future so watch out for it.