Student Nurses’ Community
NURSING CARE PLAN – Fracture ASSESSMENT SUBJECTIVE: “Nadulas ako sa hagdan, hindi ako makalakad” (I slipped down the
stairs and now I can’t walk) as
DIAGNOSIS Impaired physical mobility related to neuromuscular skeletal impairment.
INFERENCE A fracture is a break in the continuity of bone. A fracture occurs when the stress placed on a bone is greater than the bone can absorb. The stress may be mechanical (trauma) or related to a disease process (pathologic). Muscles, blood vessels, nerves, tendons, joints, and body organs may be injured when fracture occurs. Complications of fractures include problems associated with immobility (muscle atrophy, joint contracture, pressure sores), growth problems ( in children), infection, shock, venous stasis and thromboembolism , pulmonary emboli and fat emboli, and bone
PLANNING After 8 hours of nursing intervention the patient will regain or maintain mobility at the highest possible level.
INTERVENTION Independent: • Assess degree of mobility produced by injury or treatment and note patient’s perception of immobility. •
RATIONALE Patient may be restricted by selfview or selfperception out of proportion with actual physical limitations requiring interventions to promote progress toward wellness. Provides opportunity for release of energy, refocuses attention, enhances patient’s self control or self worth and aids in reducing social isolation. Increases blood flow to muscle and bone to improve muscle tone, maintain joint mobility; prevent contractures or atrophy and calcium resorption from disease. Useful in maintaining
EVALUATION After 8 hours of nursing intervention the patient was able to regain or maintain mobility at the highest possible level.
verbalize by the patient OBJECTIVE: • • • Limited range of motion Decreased muscle strength Inability to move purposefully V/S taken as follows T: 37.1 ˚C P: 82 R: 18 BP: 120/ 100
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Encourage participation on diversional or recreational activities.
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Instruct patient in • assisting in active or passive range of motion exercises of affected and unaffected extremities.
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Provide footboard.
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Student Nurses’ Community
union problems. functional position of extremities, preventing complication. Improve muscle strength and circulation, enhances patient control in situation, and promotes selfdirected wellness. Prevents or reduces incidence of skin and respiratory complication. Keeps the body well hydrated, decreasing the risk of urinary infection, stone formation, and constipation.
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Assist with or encourage selfcare activities.
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Reposition periodically and encourage coughing or deep breathing exercises. Encourage increased fluid intake to 20003000 mL/day (within cardiac tolerance), including acid/ash juices.
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Collaborative: • Refer to a therapist as indicated.
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Done to promote bowel evacuation.