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Patients Name: Johanny Jaromay Medical Diagnosis: Fracture Cl M3 Femur at left knee; Fracture Cl Patella at left kneeAge: 32 / Address: Paranaque City Date Admitted: October 23, 2006

ASSESSMENT DIAGNOSIS RATIONALE PLAN INTERVENTION RATIONALE EVALUATIO

N

Subjective:

The patient

verbalized, Hindi ko pa rin

maigagalaw ang paako. Nabali kasi ung

buto ko sa hita kayanga nilagyan muna

nila ng traction.

Objectives:

- Noted deformityof thigh due to

fracture- Limited ROM of

left lowerextremity

- Presence ofrestrictive

device (skeletaltraction)

- Insertion ofsteinmann pin

Partiallyimpaired

physicalmobility related

tomusculoskeletal

disorder(femoral

fracture) andexternal device

(skeletaltraction)

Femoral fractures areseen to those people who

have been involved in amotor vehicle crash or

who have fallen from ahigh place. The patient

presents with, enlargeddeformed, painful thigh

and cannot move the hipor the knee.

Skeletal traction isapplied directly to the

bone to treat fractureslike the femur by use of

metal pin (steinman pin)that is inserted through

the bone distal to thefracture. Often skeletal

traction is balancedtraction, which supports

the affected extremitythus limits patients

mobility but it alsoallows for some patient

movement.

Goal: After 4hours of

nursingintervention,

the patientwill be able to

maintainposition of

function withmaximum

mobilitywithin the

therapeuticlimits of

traction.

1. Assess for correctposition of traction and

alignment of bones

2. Maintain limbs in

functional alignment(with pillows, sandbags,

etc.). Support feet indorsiflexed position

3. Perform passive and

active ROM exerciseson extremities and

joints, using slowsmooth movements on

the unaffected bodyparts

4. Allow patient to

perform tasks at hisown rate. Encourage

independent activity asable as safe.

1.To maintain good bodyalignment when

mechanical devices areused

2. This prevents footdrop

and excessive plantarflexion

3. Enhances circulation

maintains muscle toneand joint mobility and

prevents disusecontractures and muscle

atrophy.

4. To increase patients

recovery and increase hisself-esteem.

After thenursing

intervention, thepatient was able

to maintainposition of

function andexerted

maximummobility within

the therapeuticlimits of

traction.

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Reference:

Medical Surgical Nursing

(Brunner and Suddarths)

5. Encourage use of

trapeze

6. Instruct and assist in

position changes andtransfers.

7. Keep side rails upand bed in low position

5. Strengthen shoulders

an arm musclesnecessary for safe

positioning andmobilization

6. Encourages active

participation whilepreventing stress on

fractured bone

7. This promotes a safeenvironment.