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Subjective
Pt screams when staff attempts to move the left lower extremity.
Pt demonstrates difficulty with any movement of the left lower extremity.
Objective
Pt states that his pain level is a 9 on a 10 point pain rating scale.
Pt grimaces during any kind of motion or movement
of his left lower extremity
Pt’s ORIF surgery
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Problem:
Impaired Physical Mobility
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Long Term:
Pt will be able to ambulate around the nurses’ station 2X by discharge.
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* Apply any ordered brace before mobilizing
the client.
Rationale:
“Brace support and stablilize a body part,
allowing increased mobility.” (Ackley & Ladwig, 2008, p 552).
*Increase independence in ADLs
Rationale:
“Providing unnecessary assistance with transfers
and activities may promote dependence and a loss of mobility.” (Ackley & Ladwig,
2008, p 552).
*Obtain any assistive devices needed for activity.
Rationale:
“Assistive devices can help increase mobility.”
(Ackley & Ladwig, 2008, p 552).
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X
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Goal met. Pt was able to ambulate around the
nurses’ station by discharge. Pt was
able to complete his activity more than twice. Pt did not complain of any pain or
discomfort upon ambulation.
Pt states “I feel like I’m finally getting
back to my old self.”
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Continue interventions as listed. Encourage
pt to continue the use of braces and assistive devices after discharge until he
feels comfortable c/o. Encourage the pt to continue his independence in ADLs and
c/o unnecessary assistance.
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R/T:
Acute pain, secondary to fractured left femur
ORIF surgery
Anxiety
Musculosketeal impairment
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Short Term:
Pt will perform passive range of motion exercises by the end of this shift.
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*Assess the pt’s pain by using the 10 point pain rating scale q4 hrs or PRN.
Rationale:
“Single- item ratings of pain intensity are valid and reliable as measures of pain
intensity.”
“The client’s report of pain is the single most reliable indicator of pain.”
(Ackley & Ladwig, 2008, p. 604-605).
*Before activity, treat pain.
Rationale:
“Pain limits mobility and is often exacerbated by movement.” (Ackley & Ladwig,
2008, p 552).
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X
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Goal met. Pt able to fully complete passive range of motion exercises with assistance
from the staff by the end of this shift. Pt did not complain of any pain associated
with exercise session.
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Continue interventions as listed. Continue to assess pain using the 10 point pain
scale q4 hrs or PRN. Continue to provide pain control and treat as needed.
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