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Nursing Diagnosis Impaired physical mobility related to pain and use of immobilization devices as manifested by with reluctance to attempt movement, limited ROM, decreased muscle strength/control,inability to mov e purposefully within the physical environment, impo sed restrictions, andverbalization of nahihirapan ako sa paggalaw-galaw. Nursing Goal After 2-3 days of providing appropriate nursing interventions, the patient will have an improved adaption to condition and will experience ease in physical mobility. Nursing Interventions 1.Assist client reposition self on a regular schedule as indicated by individual situation. : To avoid pressure ulcers.2.Instruct use of side rails and overhead trapeze for position changes/transfers. RATIONALE: For safety and ease of movement. 3. Assess degree of immobility produced by pain. RATIONALE: Level of activity/exercise depends on progression/resolution on inflammatory process. 4. Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. RATIONALE: Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility. 5.

Encourage patient to maintain upright and erect posture when sitting, standing, and walking. RATIONALE: Maximizes joint function, maintains mobility. 3.Nursing Diagnosis Risk for peripheral neurovascular dysfunction related to interruption of blood Flow secondary to disease condition. Nursing Goal After 2-3 days of providing appropriate nursing interventions, the patient will have a diminished risk to acquire peripheral neurovascular dysfunction. Nursing Interventions 1.Assess general condition of and contributing factors to patient. RATIONALE: Provide basis for understanding general, current situation of client.2.Evaluate presence/quality of peripheral pulse distal to injury via palpation. RATIONALE: Decreased/absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status.3.Assess capillary return, skin color, and warmth distal to inflammation. RATIONALE: Return of color should be rapid (3-5 secs.). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment.4.Maintain elevation of inflamed extremity unless contraindicated by confirmed presence of compartmental syndrome. RATIONALE: Promotes venous drainage/decreases edema. 5.Investigate sudden signs of limb ischemia, e.g., decreased skin temperature, pallor, and increased pain. RATIONALE:

Osteomyelitis may cause damage to adjacent arteries, with resulting loss of distal blood flow.6.Encourage patient to routinely exercise digits/joints distal to inflammation. RATIONALE: Enhances circulation and reduces pooling of blood, especially in the lower extremities.

1.Nursing Diagnosis Acute pain related to inflammation and edema as manifested by guarding behaviour, restlessness, pain scale of 7/10 and verbalization of ang sakit tlaga ng hita ko Nursing Goal SHORT TERM: After 2-4 hours of providing appropriate nursing interventions, the patient will experience decreased perception of pain as manifested by decreased restlessness, patient will be more relaxed, decreased pain scale will be assessed and patient will verbalize decreased perception of pain.LONG TERM: After 6-8 days of providing appropriate nursing interventions, the patientsinflamm ation and edema will be decreased. Nursing Interventions 1. Elevate the legs. RATIONALE: To reduce swelling in the extremity affected.

2. Handle extremity with great care and gentleness. RATIONALE: The wound itself is sometimes very painful and must be handled carefully and slowly. 3. Immobilize the affected area with a splint. RATIONALE: To reduce pain and muscle spasms. 4.Provide quiet and calm environment RATIONALE: To reduce stimulus thus promoting relaxation. 5. Encourage patient perform focused breathing. RATIONALE: This is a relaxation exercise which can alleviate the pain. 6.Encourage diversional activities (e.g. watching TV, listening to music, indoor games).RATIONALE: This is helpful to distract patient from the pain. 7.Teach patient good body mechanics RATIONALE: To minimize pain in daily activities. 8.Encourage adequate rest and sleep periods RATIONALE: To prevent fatigue. 9.Discuss with significant others ways in which they can assist client and to reduce precipitating factors that may cause/aggreviate pain. RATIONALE: To gain SOs cooperation in care of the patient. 10. Administer analgesics as prescribed. RATIONALE: To provide fast relief of pain and/or decrease intensity of pain.

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