Nursing Care Plan

Name Of Patient: F.D Name of student: Yeana S. Alon

Age: 60 y.o Year & Sec: BN4B
Sex: Male
Date of Admission: June 12, 2010
CC: blunt abdominal trauma s/t fall
Medical Diagnosis: Right Acetabular fracture
Assessment Nursing
Nursing Diagnosis Rationale Nursing Intervention Justification Evaluation
Data Objectives
Actual/Abnormal Impaired physical Predisposing factor: After 24hrs. of After 24hrs. of
Cues: mobility R/T Age (60y.o) nursing intervention, nursing intervention,
• Limited ROM musculoskeletal Precipitating factor: my client will be Independent: my client:
(client can’t impairement AEB Sudden injury due to able to: 1.1 Assess v/s and 1.1 Determine if
move right limited range of fall 1. Maintain or check the affected there are any
leg) motion, limited increase strength part of the body abnormal results
• Slowed ability to perform and function of in the v/s and to
movement ADL & decreased Right acetabular affected and/or evaluate level of
muscle fracture compensatory 1.2 Assist patient to mobility.
• Limited ability strength/control S/T body part at the do active ROM 1.2 To improve
and difficulty
right acetabular Break in the highest possible exercises on the muscle strength
to perform
fracture continuity of level. lower extremities and joint
ADL
the bone 1.3 Support affected mobility.
Definition: body parts/joints
Risk Related
Limitation in using pillows/rolls, 1.3 To maintain
Factors:
independent, Disruption of etc. position of
• Coughing and purposeful physical surrounding tissues, 1.4 Assist client/SO’s to function and
sudden body movement of the periosteum, blood develop plan for reduce risk of
movement body or of one or vessel and nerve activity and exercise pressure ulcers.
causes pain at more extremities. supply. within individual 1.4 To maintain
the affected
2. Participate in ability. strength and
part. SOURCE: recommended muscle tone and
• Age Doenges, Moorhouse, Damaged bone tissue treatment 2.1 Provide health to enhance
Geissler-Murr program. teaching regarding sense of well-
2004, Philadelphia fracture. being.
Strength/Wellness Nurse’s Pocket Deformity 2.1 To help client
: Guide: Ninth Edition 2.2 Promote over all understand his
• Strong family health measures condition
support Limited range of (e.g. nutrition, 2.2 To maintain
• Complies to motion, limited adequate fluid continuity of care
treatment ability to perform 3. Verbalize intake and rest and to avoid
regimen ADL & decreased understanding of periods, vit. recurrence of
muscle situation/risk supplements) fatigue.
strength/control. factors & 3.1 Plan care to
individual allow individually
treatment adequate rest 3.1 To maximize
Impaired physical regimen & safety periods and participation &
mobility measures schedule activities reduce fatigue.
for periods when the
client has the most
energy.
SOURCE:
Doenges, Moorhouse,
Geissler-Murr
2004, Philadelphia
Nurse’s Pocket Guide:
Ninth Edition