References 1. Potter and Perry
2. Nursing diagnosis cards by Taylor and Ralph
3. Mosby’s Nursing skills (website)
4. Clinical nursing skills (Smith)
Diagnosis 2 (Maslow’s hierarchy of needs : safety)
Impaired physical mobility related to Open Reduction, Internal Fixation (ORIF). As evidence by Pt. having intrameduillary interlocking rods in right and left bilateral femurs (3). Physician order pt. to remain in bed and catheter placed in patient’s bladder, which leads to and can cause 2 … (diagnosis 3 impaired Urinary elimination and 2 pain)
Intervention 1: position patient to maintain proper body alignment, to maintain joint function, prevent musculoskeletal deformities and help manage pain (…..draw line in pain)
Planning: according to physician when patient is at >30 degrees be placed in TLSO (breast brace) for spinal inflammation. Inform night RN and night aids, and OT that every time patient is elevated or repositioned patient be placed in her TLSO.
Evaluation: Patient maintains muscle strength and joint ROM, while keeping spine in proper alignment.
Rationale: proper body alignment and maintaining proper position in bed prevents musculoskeletal deformities, joint contractures and maintain joint function (1 pg 1043 and 2)
Intervention 2 turn and position patient every 2 hours. (….draw a line to possible skin breakdown)
Planning: Establish a turning schedule for patient, coordinate with CNA and night RN and post at bedside and monitor frequency.
Evaluation: Patient maintains muscle strength, joint ROM and maintains skin integrity. (draw a line to skin breakdown)
Rationale :Repositioning redistributes pressure and pressure on the bony prominences (2 and 1 pg 1073)
Assess pt physiologic response (monitor vital signs) to increased activity during occupational therapy (OT)
Planning: physician ordered OT 3 times a day. Each session patients day RN or CNA should take and document patients vital signs to check response to increased activity. Explain to patient symptoms of over exertion such as dizziness, dyspnea and increased pain (2)(….draw a line to pain)
Evaluation: Patient performs ROM (as ordered by physician) with OT, and tolerance level monitored to control patients pain.
Rationale: Continuous evaluation and documentation helps assess tolerance for increased exertion and activity as well as pain tolerance. It allows RN to assess the need to speak to the physician to recommend change in therapies as well as provides comparison for future measurements. (1 pg 1043 and 2)
Intervention 4 Teach patient methods to maximize patient’s participation in self care by offering positive feedback and emotional support.
Planning: Determine type and amount of assistance pt will need to perform a partial bath, mouth care, washing and brushing her hair. If patient is able to perform any hygiene care on her own contact OT and pts nursing and tell them pt can participate in her own oral and hair care.
Patient performs self-care activities to her tolerance lever
Having the patient participate in her own care allows the patient to have more self-esteem and motivation to regain ability to perform ADLs. Also communication among the staff members ensures continued care , and helps preserve and regain independence (1, 2)
Improve environmental safety as needed. Make changes in patient’s environment that may cause or contribute to injury.
Planning: Assess patient’s ability to use call bell, side rails and bed positioning controls. Keep bed as low as possible. Make sure patient’s call light is within reach, also explain to patient if she wants to be elevated in bed she must contact RN or CNA to put on her TLSO. Have patents RN document file to let other medical personnel know about TLSO.
Evaluation: patient will develop strategies to maintain her safety.
References: Rationale :Repositioning redistributes pressure and pressure on the bony prominences (2 and 1 pg 1073)
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