Ncp Ortho

BUENAVENTURA, EDWIN Age: 18 Date Admitted: June 1, 2009 Address: Navotas City Assessment Subjective: “masakit ang balakang ko, hndi ako makatayo ng tuwid..” -as verbalized by the patient Objective: -slowed movement -limited range of motion -facial grimace -pale -weak in appearance

Diagnosis Impaired Physical Mobility related to Activity Intolerance

Planning After 3-4 days of nursing interventions the patient will be able to: -verbalize understanding of situation and individual treatment regimen and safety measures - demonstrate techniques / behaviors that enable resumption of activities -maintain or increase strength and function of affected and / or compensatory body

Intervention Note situations such as surgery, fractures, amputation, tubings (chest, catheter, etc)

Rationale -may restrict movement

Assess degree of pain, listening to client’s description

-to identify causative factors

Ascertain client’s perception to activity / exercise needs

-to identify contributing factors

Observe movement when client is unaware of observation

-note any incongruencies with reports of abilities

Note emotional / behavioral responses to problems of immobility

-feelings of frustration / powerlessness may impede attainment of goals

Assist / have client reposition self on a regular schedule by individual situation Administer medications prior to activity as needed for pain relief Schedule activities with adequate rest periods during the day Identify energy conserving techniques for ADLs

-to promote optimal level of function -to permit maximal effort / involvement in activity -to reduce fatigue -limits fatigue, maximizing participation

Evaluation After 3-4 days of nursing interventions, goal was met as evidenced by the patient. Patient has: -verbalize understanding of situation and individual treatment regimen and safety measures - demonstrate techniques / behaviors that enable resumption of activities -maintain or increase strength and function of affected and / or compensatory body