N Osteomyelitis e4b9

Assessment

Subjective:

Objective:  Limited ROM  Slowed movement  Inability to perform gross/ fine motor skills.  Gait changes  Difficulty of turning

Diagnosis

Impaired physical mobility r/t Neuromuscular skeletal impairment.

Planning

After 8 hours of Nursing Intervention the patient will able to:

Intervention

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

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Instruct patient in/assist with active/ive ROM exercises of affected and unaffected extremities.

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Increases blood flow to muscles and bone to improve muscle tone, maintain t mobility; prevent contractures/atro phy and calcium resorption from disuse.

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Provide footboard, wrist splints, trochanter/ hand rolls as appropriate.

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Useful in maintaining functional position of extremities, hands/feet, and preventing complications (e.g., contractures/ foot drop).

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Assist with/encourage self-care activities (e.g., bathing, shaving).

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Improves muscle strength and circulation, enhances patient control in situation, and promotes selfdirected wellness.

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Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures.

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Reduces risk of flexion contracture of hip.

a. Cooperate with the student nurse in treatment regimen and safety measures. b. Participate in ADLs and desired activities such as eating, maintenance of proper hygiene.

Rationale

Patient may be restricted by selfview/selfperception out of proportion with actual physical limitations, requiring information/interv entions to promote progress toward wellness.

Evaluation

After 8 hours of Nursing Intervention the patient was able to: a. Cooperate with the student nurse in treatment regimen and safety measures. b. Partially participate in ADLs and desired activities such as eating, maintenance of proper hygiene.

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Provide/assist with mobility by means of wheelchair, walker, crutches, and canes as soon as possible. Instruct in safe use of mobility aids.

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Early mobility reduces complications of bed rest (e.g., phlebitis) and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety.

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Encourage increased fluid intake to 2000–3000 ml /day (within cardiac tolerance), including acid/ash juices.

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Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation.

Assessment

Subjective:

Objective:  Pain scale 8/10  Facial Grimace  Limited ROM  Slowed movement

Diagnosis

Acute pain r/t inflammation and swelling.

Planning

After 8 hours of nursing intervention the patient will able to reduce the pain from level 8 to level 2 of pain.

Intervention

Rationale

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Encourage patient to verbalize about pain.

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Promotes cooperation from the client.

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Encourage patient to do deep breathing exercises

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To promote relaxation, decrease perception of pain, increase oxygen circulation.

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Encourage adequate rest period

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To promote relaxation and prevent fatigue.

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Perform nonpharmacolog ical interventions such as music therapy and gentle massage

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Nonpharmacological treatments promote relaxation and distract perception to pain.

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Provide comfort measures such as cold compress and pillows

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Comfort measures such as cold compress relieve pain and pillows reduce tension

Evaluation

After 8 hours of nursing intervention, goal met, the patient was able to reduce the pain from level 8 to level 2 of pain.