NCP FOR VEHICULAR ACCIDENT

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired physical Short term goals: ASSESSMENT GOAL MET.
“I have difficulty mobility r/t activity After 8 hours of Independent After 8 hours of
moving, intolerance, nursing Interventions nursing interventions,
especially my neuromuscular/ interventions, pt 1. Assess the degree of The patient may be pt:
legs.” As musculoskeletal will: immobility produced restricted by self-view or -Verbalized
verbalized by pt impairment, -Verbalize by injury or treatment self-perception out of understanding of
prescribed understanding of and note the patient’s proportion with actual situation, and
movement situation, and perception of physical limitations, individual treatment
restrictions as individual treatment immobility. requiring information or regimen and safety
Objective: evidenced by limited regimen and safety interventions to promote measures.
-cuts in ankle and ROM, limited ability measures. progress toward wellness.
knee to perform gross or
-limited ROM fine motor skills, After 1 week of
-limited ability to slowed movement Long term goals: Monitor blood pressure Postural hypotension is a nursing interventions,
perform gross or and decreased After 1 week of (BP) with the common problem pt:
fine motor skills muscle nursing resumption of activity. following prolonged bed
-slowed strength/control interventions, pt Note reports of rest and may require -participate in ADL’s
movement will: dizziness. specific interventions (tilt and desired activities.
-decreased -demonstrate table with gradual
muscle techniques or elevation to the upright -maintain position of
strength/control behaviors that position). function and skin
enable resumption of THERAPEUTIC integrity.
activities. INTERVENTIONS
-participate in -has increased
ADL’s and desired 1. Encourage Provides an opportunity strength and function
activities. participation in to release energy, of affected body part
-maintain position of diversional or refocuses attention, as evidenced by
function and skin recreational activities. enhances patient’s sense participation in ROM
integrity. Maintain a stimulating of self-control and self- exercises.
-maintain or increase environment (radio, worth, and aids in
strength and TV, newspapers, reducing social isolation. -demonstrated
function of affected personal possessions, techniques or
or compensatory pictures, clock, behaviors that enable
body part. calendar, visits from resumption of
family and friends). activities as evidenced
Increases blood flow to by good responses to
2. Teach patient or muscles and bone to interventions,
assist with active and improve muscle tone, teachings and actions
passive ROM exercises preserve joint mobility, performed.
of affected and prevent contractures or
unaffected extremities. atrophy, and calcium
resorption from disuse.

Useful in maintaining a
3. Provide footboard, functional position of
wrist splints, extremities, hands, and
trochanter, or hand feet and preventing
rolls as appropriate. complications
(contractures, foot drop).

Facilitates movement
4. Instruct and during hygiene or
encourage the use of skincare and linen
trapeze and changes; reduces the
“postposition” for discomfort of remaining
lower limb fractures. flat in bed. “Post
position” involves
placing the uninjured foot
flat on the bed with the
knee bent while grasping
the trapeze and lifting the
body off the bed.
 Improves muscle strength
5. Assist with self-care and circulation, enhances
activities (bathing, patient control in the
shaving). situation and promotes
self-directed wellness.

Early mobility reduces

6. Provide and assist complications of bed rest
with mobility aids such (phlebitis) and promotes
as wheelchairs, healing and normalization
walkers, crutches, and of organ function.
canes. Learning the correct way
to use aids is important to
maintain optimal mobility
and patient safety.

Prevents or reduces the

7. Reposition incidence of skin and
periodically and respiratory complications
encourage coughing (decubitus, atelectasis,
and deep-breathing pneumonia).
exercises.

Knowledge will help

8. Instruct the patient ensure optimal healing
and family in care of an and immediate
extremity in external interventions in case of
fixator, the complications.
performance of
prescribed exercises
while in the fixator, and
signs and symptoms of
complications.

Helps promote regular

9. Initiate bowel bowel evacuation.
program (stool
softeners, enemas,
laxatives), as indicated.
Effective pain
10. Teach the patient intervention will enhance
and significant others the patient’s ability to
(SO) about the use of engage in appropriate
analgesics and instruct activity and exercises.
nonpharmacological
pain management such
as imagery, relaxation,
and distractions.

Interdependent
Intervention Useful in creating
11. Consult with a individualized activity
physical, occupational and exercise programs.
therapist, or The patient may require
rehabilitation specialist. long-term assistance with
movement, strengthening,
and weight-bearing
activities, as well as the
use of adjuncts (walkers,
crutches, canes); elevated
toilet seats; pickup sticks
 or reachers; special eating
utensils.

Patients or SO may
12. Refer to psychiatric require more intensive
clinical nurse specialist treatment to deal with the
or therapist as reality of current
indicated. condition, prognosis,
prolonged immobility,
perceived loss of control.