DATA Subjective: Sakit ilihok kung alsahon ko as verbalized by the patient.

8/10 pain scale upon exertion Objective: Dry skin Pale nailbeds Weakness Fatigue Non- ambulatory Swelling on the left left thigh - Restlessness - irritability - Vital signs: T- 36.5 PR- 84 RR- 20 BP- 110/ 80

NURSING DIAGNOSIS

OBJECTIVES Short term:

Impaired physical mobility related to Fear of movement and confinement in traction.

At the end of the shift, patient will be able to demonstrate techniques that will enable resumption of activities with comfort. Long term: At the end of 3 days intervention, patient will be able to accept the maximum physical mobility within limitations imposed by physical condition and treatment plan.

NURSING INTERVENTION Independent: 1. Vital signs monitoring and recording 2. Asses for factors that impair physical mobility 3. Place pillows/ blankets on the side of the leg 4. Assist the patient in doing his ADL. 5. Instruct the patient to stop any activities that causes chest pain, shortness of breath, or weakness 6. Encourage significant others to use comfort measures like therapeutic touch and being involved in assisting and providing care

RATIONALE

1. To have a baseline data and to monitor for any irregularities 2. To determine the limitations on how to assist the patient 3. To promote comfort on affected leg 4. To gain his trust, helps in regaining his comfort on unaffected areas 5. To stop any more possible complications 6. Promote cooperation and support that can uplift the patients spirits and outlook in life

DATA Subjective: Sakit kayo ako tiil labi na gyud mag lihok ko as verbalized by the patient P- sakit kung maglihok ko Q-mura siya ug ga ngulngol R- pati na akong likod gasakit S -8/10 T- sa paglihok sa ako hantod mga napulo-baynti minutos pag makahigda nako Objective: -facial grimacing -diaphoresis -guarding on affected area -Swelling -on ambulatory -Discomfort -Irritability

NURSING DIAGNOSIS Chronic pain related to bone infection secondary to the disease process

OBJECTIVES Short term: At the end of the shift client will experience diminished pain as evidenced by: 1. Verbalization of pain relief 2. Relaxed facial expression 3. Relaxed body positioning 4. Increased participation on activities Long term: At the end of 3day nursing interventions patient will verbalize alleviation of pain with reduced number of pain scale.

NURSING INTERVENTION INDEPENDENT: 1. Position patient in a comfortable position (semi/high fowlers) 2. Implement measures to reduce pain such as: a. Maintain a restful environment b. Relaxation techniques c. Diversional activities 3. Instruct patient in responsible administration of all medications 4. Reduce unsafe activities and behaviors, or modify if appropriate 5. Maintain vigilance and supervision when needed 6. Evaluate patients for existing diseases and their effect on patients current problem

RATIONALE 1. Promote comfort and prevention of bed sores 2. For fast healing psychologically and physiologically 3. Prevents mistakes causing over doses and untoward side effects, leading to accidents 4. Reduce risk of falls 5. Accident prevention maintains safety of patient. 6. May indicate the presence of compartment syndrome, which requires emergency treatment to prevent necrosis and loss of tissue

DATA

NURSING DIAGNOSIS Risk for situational low self- esteem related to change body image due to swelling of left lower extremity.

OBJECTIVES

Subjective: Niwang nakaayo ko ,sukad pagkadisgrasya naku, sauna katong wala paku nahitabo 75 kilos ko karon murag 50 nlng guro ko as verbalized by the patient. Objectives: Undesired weight loss Pallor Dry Skin Edema Fear of Death

Short term: At the end of the 8hr duty, patient will verbalize the importance of self-worth, belief in fast healing and verbalize knowledge upon the disease process. Long term: At the end of the 3day duty, patient will demonstrate better outlook in life, cooperation and willingness in the treatment plan.

NURSING INTERVENTION 1. Assess patients and familys responses and reactions to illness and treatment 2. Assess relationship of patient and significant family members 3. Assess usual coping patterns of patient and family members 4. Explore alternative ways of sexual expression other than sexual intercourse 5. Discuss role of giving and receiving love, warmth, and affection

RATIONALE 1. Provides data about problems encountered by patient and family in coping with changes in life 2. Identifies strengths and supports of patient and family 3. Coping patterns that may have been effective in past may be harmful in view of restrictions imposed by disease and treatment 4. Alternative forms of sexual expression may be acceptable 5. Sexuality means different things to different people, depending on stage of maturity

Data Subjective: Imbis mag anhi me diri para ipakuha ang puthaw ge admit nalang ko sa doctor kay ga hubag akong ga hubag akong pa as the pt verbalized Objective: Non-ambulatory Swelling of left femur Presence of abscess Pain scale 8/10 Vital Signs: T- 36.5 PR- 84 RR- 20 BP- 110/ 80

NURSING DIAGNOSIS Knowledge deficit regarding follow-up care

OBJECTIVES

Long term : At the end of 3 day nursing interventions, patient will verbalize and demonstrate understanding on doing follow-up care . Short term: At the end of the shift, patient will identify ways to prevent postoperative infection, demonstrate the ability to perform wound care, state sign and symptoms of complications to report to the health care provider.

NURSING INTERVENTION 1.maintain balanced nutrition intake. 2.maintain good personal hygiene 3.avoid touching any wound unless it is completely healed 4.maintain sterile or clean technique during wound care. 5.educate the patient about the proper positioning. 6.prevention of pressureon suture line/affected area 7.verbalization of any discomfort

RATIONALE 1.to sustain vitamins and minerals to the body. 2.to promote a healing environment. 3.to avoid disruption of the healing process 4.to prevent infection and complications 5.to prevent unnecessary injury. 6.to avoid any more complications and more damage on the affected site 7.to monitor the condition of the affected area and the patient

Data Subjectives: Nag nana na ni daan akong tiil na wala before ko nag anhi sa hospitalas the pt verbalized Objectives: *Swelling left side of lower extremity *pain scale 8/10 *non-ambulatory *dry skin *Purulent drainage

NURSING DIAGNOSIS Ineffective tissue perfusion related to tissue swelling

OBJECTIVES Short term: At the end of the shift, patient will manifest normal values of vital signs, good skin integrity and normal urine output. Long term: At the end of 3day duty patient will be able to be relieved of the signs of symptoms of diminished tissue perfusion.

NURSING INTERVENTION 1. remind patient not to smoke 2. discourage intake of food/fluid high in caffeine 3.maintain fluid and dietary sodium restrictions as ordered 4. .keep bed as flat as possible to reduce shearing forces limit fowler position to 30 mins. 5 .use enough personnel to lift person up in bed. 6. .reduce pressure to infected area.

RATIONALE 1. smoking causes vasoconstriction 2.caffeine stimulates sympathetic nervous system 3. to reduce fluid retention

4. for safety measure of the pt 5. for the safety measure because he is dependent in every activity. 6. less infectious and shorten the healing process