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Nursing Diagnosis Impaired physical mobility, inability to stand alone related to skeletal impairment to facture of the left femoral neck
Analysis Fractures occur when the bone is subjected to stress greater that it can absorb. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joints dislocations, ruptured ten-dons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that caused the fracture fragments. After a fracture, the extremities cannot function properly because normal functions of muscle depend on the integrity of the bones which they are attached.(Gulanick &Myers: 2007, p.126)
Objectives After 8 hours of rendering nursing intervention, the patient will be able to: Increase strength and function of affected body part Move within range of motion
Rationale
Evaluation After 8 hours of rendering nursing care, the goals was met as evidenced by: Move within range of motion Demonstrat e increasing function of the extremities. Regain or maintain mobility at the highest possible level.
Until healing occurs, activity Is limited and advanced slowly according to individual tolerance
Have normal Respiratory Rate. Recite the nonpharmacologi c ways to lessen pain. Demonstrate the nonpharmacologi c ways to lessen pain.
Encourage and facilitate early ambulation and other ADLs when possible Assist with each initial change: dangling, sitting in chair, ambulation
The longer the patient remains immobile the greater the level of debilitation that will occur
Verbalize understandi ng of the situation /risk factors , individual therapeutic regimen and safety
DEPENDENT: Administer analgesic medication: Ketorolac IVTT x 4doses q 8 hours as prescribe by the physician.