H.E.

Observe for signs of hemorrhage and measure extent of drainage on cast when
present, observe for swelling, observe for signs of infection, observe for signs of
thrombophlebitis, encourage high protein, high vitamin diet to promote healing.
Avoid excessive use of injured extremity, blow cool air from hair dryer.

Assessment
S:hindi ako makagalaw ng aus ang binti ko, as verbalized by the patient.
O: slowed movement, limited range of motion, limited ability to perform gross and
fine motor.
Diagnosis:
Impaired physical mobility related to muscoskeletal impairment as manifested by
inability to move.
Planning
At the end of 6 hours nurse- patient interaction, the patient will
*verbalize understanding of situation and individual treatment
* participate in activities of daily living
* maintain position of action and skin integrity as evidence by absence of decubitus
ulcer
*maintain and increase strength and function of the affected part.
Intervention
*determine degree of immobility.
*determine presence of complications related to immobility.
* assist client reposition self on a regular schedule.
*consult with physical or occupational therapist, to develop individual exercise and
mobility program, and appropriate mobility devices.
*encourage adequate intake of fluids and nutritious foods because it promotes
wellbeing and maximizes energy production.

Evaluation
At the end of 6 hours nurse- patient interaction, the patient has:
*verbalized understanding of situation and individual treatment
* participated in activities of daily living
* maintained position of action and skin integrity as evidence by absence of
decubitus ulcer
*maintained and increased strength and function of the affected part.