Read carefully the clinical situation and accomplish the task required.

J.R. is a 28 year old male , single, had sustained Right lower leg comminuted fracture
from a motorcycle accident . He was direct to OR for ORIF with metal plates and screws.
He had a posterior mold cast too. He had been in the hospital for 3 days now.
1. Alteration in comfort
Alteration in comfort is a state in which a person has perceived lack of ease, relief, and
transcendence in physical, psychospiritual, environmental, cultural, and/or social
dimensions. This can happen because MS Ortho patients are commonly experiencing
disorder or deformities that affects their bones, joint, muscles, tendons, nerves and
skins. When pain is present there is alteration in comfort. This nursing diagnosis is very
common to all patients since there would always be chief complaints and those
complaints would cause discomfort.
2. Potential for effects of Immobility
Potential for effects of immobility is a state in which a person is at risk or vulnerable for
impaired ability to ambulate or perform range of movement. This can happen because
MS Ortho patients have experienced loss of limb, stiffness, pain, weakness or inability to
bear weight from a musculoskeletal disorder, the reason why there is decrease in muscle
function, loss of muscle mass, reduction in muscle strength, gait changes affecting
balance, and stiffer.
3. Inadequate tissue perfusion

Inadequate tissue perfusion is a state in which a person has a decrease in blood

circulation to the tissue that may compromise health. This can happen when
musculoskeletal disorders or injuries such as fractures, sprains and many more occurs,
the body tend to experience a decreased in arterial blood flow that can be due to the
symptoms of these injuries such as swelling and pressure which will seriously lead to
decreased circulation distal to site of trauma because of the sudden embolic event
obstructing arterial flow.

4. Potential for Infection

Potential for infection is a state in which a person is at risk or vulnerable to invasion and
multiplication of pathogenic organisms, which may compromise health. This can happen
to MS Ortho patients due to trauma or surgical incision that they have experienced and if
aseptic technique were not practiced or signs of infection were not monitored and no
action have been taken.
5. Activity Intolerance
Activity intolerance is a state in which a person has insufficient physiological or
psychological energy to endure or complete necessary or desired daily activities. This
can happen because MS Ortho patients experience stiffness, pain, limited mobility, and
fatigue that is why they have limited activity intolerance or insufficient energy to endure
or complete required or desired daily activities.
1. Alteration in comfort

 Monitor vital signs (temperature, pulse rate, respiratory rate, blood pressure)

 Promote comfort by making sure patient is positioned properly

 Encourage deep breathing exercise

 Provide stress less and comfortable environment for the patient.

 Use relaxation technique such as heat and cold application

2. Potential for effects of Immobility

 Active ROM at least TID for all unaffected joints while on bed rest.

 Passive ROM on affected joints as ordered.

 Ensure that joints are in correct alignment when at rest and after turning. Maintain body
in proper alignment.

 Supervise exercise to prepare muscles for ambulation.

 Instruct in use of ambulatory devices as appropriate; supervise practice; assess for

proper “fit” of device.
3. Inadequate tissue perfusion

 Perform neurovascular assessment hourly for 8 hr, then q2h for 48 hr. Question patient
regarding sensation distal to site of trauma or surgery.

 Apply cold to area of injury or surgery, as ordered, to reduce swelling;

 Elevate extremity to slightly above heart level.

 Immediately report signs of compartment syndrome (i.e., severe, unrelenting pain;

numbness) to provider

 Obtain order for measures to relieve pressure.

4. Potential for Infection

 Follow Standard Precautions and strict Contact Precautions when performing patient
care, and use strict aseptic technique for wound or pin care.

 Assess for signs of infection every shift; assess wound for redness, swelling, and
tenderness.

 Administer prophylactic antibiotics as prescribed.

 Assess temperature trends and trend of WBC values for signs of infection.

 Assess patient for subjective signs of malaise.

5. Activity Intolerance

 Assess degree of inability to perform various self-care activities.

 Formulate plan to assist patient with ADLs. Advise of assistive devices that might make
ADLs easier and help conserve energy.
 Answer calls for assistance with toileting promptly; do not leave on bedpan longer than
necessary. Open food containers and cut food as needed for self-feeding with one hand.
Do not serve extremely hot liquids to patients who have difficulty with coordination or
with holding drinking containers or to immobilized patients.
 Provide assistive devices and help patient to be as self-sufficient as possible without
incurring undue fatigue when performing ADLs.
 Caution patients about change in body's center of gravity when a limb is casted or
amputated.