Concept Map
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)
Intervention 3
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
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)
Intervention 3
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
References: Rationale :Repositioning redistributes pressure and pressure on the bony prominences (2 and 1 pg 1073) Intervention 3