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    NCP Impaired Physical Mobility Acute Pain

    Uploaded by

    Ai Rou
    The patient experienced impaired physical mobility and alteration in comfort due to an injury. The document outlines the patient's subjective and objective cues, scientific basis, nursing diagnosis, goal to improve mobility and reduce pain, and nursing interventions with rationales. The nursing interventions included active range of motion exercises, analgesics, relaxation techniques, and education. After 8 hours the goals of increasing mobility and reducing pain were met.

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    NCP Impaired Physical Mobility Acute Pain

    Uploaded by

    Ai Rou
    2K views8 pages
    The patient experienced impaired physical mobility and alteration in comfort due to an injury. The document outlines the patient's subjective and objective cues, scientific basis, nursing diagnosis, goal to improve mobility and reduce pain, and nursing interventions with rationales. The nursing interventions included active range of motion exercises, analgesics, relaxation techniques, and education. After 8 hours the goals of increasing mobility and reducing pain were met.

    Original Title

    27634280 NCP Impaired Physical Mobility Acute Pain

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    The patient experienced impaired physical mobility and alteration in comfort due to an injury. The document outlines the patient's subjective and objective cues, scientific basis, nursing diagnosis, goal to improve mobility and reduce pain, and nursing interventions with rationales. The nursing interventions included active range of motion exercises, analgesics, relaxation techniques, and education. After 8 hours the goals of increasing mobility and reducing pain were met.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views8 pages

    NCP Impaired Physical Mobility Acute Pain

    Uploaded by

    Ai Rou
    The patient experienced impaired physical mobility and alteration in comfort due to an injury. The document outlines the patient's subjective and objective cues, scientific basis, nursing diagnosis, goal to improve mobility and reduce pain, and nursing interventions with rationales. The nursing interventions included active range of motion exercises, analgesics, relaxation techniques, and education. After 8 hours the goals of increasing mobility and reducing pain were met.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 8

    CUES

    Subjective
    cues:
    - sakit akong
    luyo ug wala
    nga tiil as
    verbalized by
    the patient.

    Objective
    cues:
    -received
    patient lying
    on bed, awake,
    coherent, &
    responsive.

    -IVF of 1 L #
    21 PLR with
    remaining 270
    mL @ 30
    gtts/min.
    infusing well

    NURSING
    DIAGNOSIS

    SCIENTIFIC
    BASIS

    GOAL &
    OUTCOME
    CRITERIA

    Impaired
    physical
    mobility,
    inability to stand
    alone related to
    skeletal
    impairment to
    facture of the left
    femoral neck

    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

    After 8 hours of
    rendering appropriate
    nursing interventions
    the patient will be
    able to:

    1. Demonstrate
    increasing
    function of
    the
    extremities.

    NURSING
    ACTIONS &
    NURSING
    ORDERS

    RATIONALE

    EVALUATION

    After 8 hours of
    rendering
    appropriate
    nursing
    interventions the
    patient was able:

    Independent
    - assist patient to
    do active ROM
    exercises on the
    lower extremities.

    -to improve
    muscle
    strength and
    joint mobility.
    (GULANICK
    & MYERS:
    2007, p. 127)

    Dependent

    -in order for


    the muscle to
    -administer
    analgesics such as be more relax
    Tramadol (Tramal) and relieves
    as prescribed by
    the pain
    the physician.
    (GULANICK

    1.Demonstrate
    increasing function
    of the extremities.

    2.Regain or
    maintain mobility
    at the highest
    possible level.

    3. Verbalize
    understanding of
    the situation /risk
    factors, individual
    therapeutic
    regimen and

    @ right arm.

    - grimace face
    noted

    - limited ROM

    because normal
    functions of
    muscle depend on
    the integrity of the
    bones which they
    are attached.

    & MYERS:
    2007, p. 127)

    -Goal was met


    Collaborative
    - consult with
    physical or
    occupational
    therapist as
    indicated.

    (Gulanick &
    Myers: 2007, p.
    126)

    -to develop
    individual
    exercise or
    mobility
    program and
    identify
    appropriate
    adjunctive
    devices.
    (GULANICK
    & MYERS:
    2007, p. 129)

    -v/s

    safety.

    BP:
    130/80
    mmHg
    T:
    38.2C
    P : 75
    bpm
    R : 20
    cpm

    Independent
    2. Regain or
    maintain
    mobility at
    the highest
    possible
    level.

    -assess degree of
    mobility produced
    by injury or
    treatment and note
    patients
    perception of
    immobility.

    -patient may
    be restricted
    by self-view
    or selfperception out
    of proportion
    with actual
    physical
    limitations
    requiring
    interventions
    to promote
    progress
    toward

    wellness.
    (GULANICK
    & MYERS:
    2007, p. 127)

    3. Verbalize
    understanding
    of the
    situation /risk
    factors,
    individual
    therapeutic
    regimen and
    safety
    measures.

    NURSING
    CUES

    Subjective
    cues:
    - sakit akong
    luyo ug wala
    nga tiil as
    verbalized by
    the patient.

    Objective
    cues:
    -received
    patient lying
    on bed,
    awake,
    coherent, &
    responsive.

    - diaphoresis

    - pain scale of
    8/10, as of 0

    SCIENTIFIC BASIS

    DIAGNOSIS

    Alteration in
    comfort : Acute
    Pain related to
    tissue trauma 2
    to MVA

    Pain is a typical sensory


    experience that may be
    described as the
    unpleasant awareness of
    a noxious stimulus or
    bodily harm.
    Individuals experience
    pain by various daily
    hurts and aches, and
    occasionally through
    more serious injuries or
    illnesses. Pain is
    defined scientifically as
    unpleasant sensory and
    emotional experience
    associated with actual
    or potential tissue
    damage, or described in
    terms of such damage.
    Pain of any type is the
    most frequent reason
    why people tend to seek
    medical consultation. It
    is a major symptom in
    many medical
    conditions, significantly
    interfering with a
    persons quality of life
    and general functioning.
    Diagnosis is based on

    GOAL &
    OUTCOME
    CRITERIA

    NURSING
    ACTIONS &
    NURSING
    ORDERS

    RATIONALE

    After 8 hours of
    rendering
    appropriate nursing
    intervention, the
    patient will be able
    to reduced pain
    from 8 to 4 with 10
    as the most painful.
    1. The patient
    will verbalize
    reduction of
    pain from a
    pain scale of 4
    in a 0-10 scale
    with 10 as the
    most painful.

    EVALUATION

    After 8 hours of
    rendering
    appropriate
    nursing
    intervention, the
    patient was able
    to have reduction
    of pain from 8 to
    4 with 10 as the
    most painful.

    Independent
    - perform proper
    nursing
    interventions and
    appropriate
    procedures to
    alleviate pain.
    -use nonpharmacologic
    interventions for
    relieving pain
    (eg. Relaxation)

    - appropriate
    measures will
    be
    implemented
    to prevent
    infections and
    complications.
    - use of nonpharmacologic
    methods will
    embrace the

    1. The patient
    will verbalize
    reduction of
    pain from a
    pain scale of
    4 in a 0-10
    scale with 10
    as the most
    painful.
    2. Patient will
    demonstrate
    ways to
    reduce pain.
    3. The patient
    will
    appreciate the
    care rendered.

    is no pian and
    10 is the most
    painful

    -guarding
    behavior

    - T : 38.2C

    O occurs
    when moving
    L on his left
    leg
    D
    approximately
    1 min.
    C gnawing
    pain
    A frequent
    moving
    R rest

    characterizing pain in
    various ways, according
    to duration, intensity,
    type (dull, burning or
    stabbing), source, or
    location in body.
    Usually, pain stops
    without treatment or
    responds to simple
    measures such as
    resting or taking an
    analgesic, and it is then
    called acute pain. But it
    may become intractable
    and develop into a
    condition called chronic
    pain, in which pain is
    no longer considered a
    symptom but an illness
    by itself. The study of
    pain has it recent years
    attracted many different
    fields such as
    pharmacology,
    neurobiology, nursing
    sciences, dentistry,
    physiotherapy, and
    psychology. Pain
    medicine is a separate
    subspecialty figuring
    under some medical
    specialties like
    anesthesiology,
    physiatry, neurology,
    and psychiatry. Pain is
    part of the bodys
    defense system,
    triggering a reflex
    reaction to retract from

    results of pain - Goal was met


    reliever. Gate
    control theory
    states that
    cutaneous
    stimulation
    closes the pain
    pathways.
    (BARE &
    SMELTZER,
    2004: 1140)
    -in order for
    the muscle to
    be more relax
    and relieves
    the pain
    Dependent

    (GULANICK
    & MYERS:
    --administer
    analgesics such as 2007, p. 127)
    Tramadol
    (Tramal) as
    prescribed by the
    physician.

    2. Patient will
    demonstrate
    ways to reduce

    Independent
    - instruct patient
    to use relaxation
    exercises such as
    focused

    -diverts
    attention and
    may enhance
    coping
    abilities.
    (DOENGES,
    2002:368)

    T Tramadol
    (Tramal)

    a painful stimulus, and


    helps adjust behavior to
    increase avoidance of
    that particular harmful
    stimulation in the
    future. Given its
    significance, physical
    pain is also linked to
    various cultural,
    religious, philosophical,
    or social issues.
    (http://en.wikipedia.org)

    pain.

    breathing,
    commercial or
    individualized
    tapes.
    Dependent
    -provide
    individualized
    physical therapy
    or exercise
    program that can
    be continued by
    the client when
    discharged.
    Collaborative
    -encourage
    patient to have
    adequate bed rest
    periods.

    -promotes
    active, not
    passive role.
    (DOENGES,
    2002: 369)

    -bed rests
    decreases
    body
    metabolism
    and thus
    reduces
    muscle
    tension.
    (BARE &
    SMELTZER,
    2004: 1140)

    - Establish a
    trusting
    relationship
    that
    encompasses
    Independent
    patients
    -establish a
    physiological,
    specific time to
    emotional,
    talk with patient
    about pain and its social, sexual,
    psychological and and financial
    emotional effects. concerns.
    (SPARKS &
    TAYLOR,
    2005: 227)

    - Pain is a
    subjective
    experience
    and cannot be
    felt by others.
    (DOENGES,
    2002: 367)

    Dependent
    -accept clients
    description of
    pain.
    3. The patient
    will appreciate
    the care
    rendered.

    - to achieve
    pain
    management
    goals and
    maximize
    patients
    cooperation.
    (SPARKS &
    TAYLOR,
    2005: 227)

    Collaborative
    -work closely
    with staff and
    patients family.

    NURSING
    CUES

    Subjective

    DIAGNOSIS

    SCIENTIFIC BASIS

    GOAL &
    OUTCOME
    CRITERIA

    NURSING
    ACTIONS &
    NURSING
    ORDERS

    RATIONALE

    EVALUATION

    cues:
    -lisod man
    ilihok akong
    lawas as
    verbalized by
    the patient.

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