Assessment Nursing Planning Implementation Scientific Rationale Evaluation

Diagnosis
 Assess patient’s  Provides basis for
 Verbalization Deficient After 8 hours of knowledge of teaching and After 8 hours of
of the problem Knowledge and nursing disease, diet, techniques to nursing
and request Osteoporotic intervention, the medication, and promote intervention, the
for information process and patient will be exercise program to compliance. patient was able to
 Fear of further treatment able to: arrest progression of Disease is not accurately verbalize
bone loss and regimen bone deterioration. usually detected understanding of
fractures  Achieve until 24-40% of medications and
 Presence of increased calcium in bone is methods of
preventable knowledge lost. administration and
complication and  Assess the patient’s  Most individuals patient exhibits no
compliance understanding of with osteoporosis injury, fall, or
with medical osteoporosis. are not diagnosed trauma that may
regimen to until an acute predispose to a
minimize fracture occurs. fracture.
bone  Assist to plan  Exercise will
demineralizat exercise program strengthen bone.
ion and according to
injury. capabilities.
 Compliant  Teach patient about  Adequate calcium
with nutrition and calcium helps to prevent
medication intake. osteoporosis.
and dietary  Instruct patient in  Prevents injury that
instructions. methods to perform can occur with
 Perform daily activities of daily osteoporosis with
exercises living and to avoid minimal trauma.
within lifting, bending, or
identified carrying heavy
limitations objects.
and to
prevent
further bone
loss or
deterioration.
 Assessment Nursing Planning Implementation Scientific Rationale Evaluation
Diagnosis

 Reports of Acute Pain After 8 hours of  Maintain  Relieves pain and After 8 hours of
pain related to nursing immobilization of prevents bone nursing
 Distraction; Fracture and intervention, the affected part by displacement and intervention, the
self- muscle spasm patient will be means of bed rest, extension of tissue patient was able to
focusing/narro able to: cast, splint, traction. injury. verbalize decrease
wed focus;  Elevate bed covers;  Maintains body pain intensity and
facial mask of  Verbalize keep linens off toes. warmth without demonstrate use of
pain relief of pain. discomfort. relaxation
 Guarding,  Display  Evaluate and  Absence of pain techniques and
protective relaxed document reports of expression does understanding of
behavior; manner; able pain or discomfort, not necessarily the importance of
alteration in to participate noting location and mean lack of pain. non-pharmacologic
muscle tone; in activities, characteristics, nursing pain
autonomic sleep/rest including intensity management.
responses appropriately (0–10 scale),
. relieving and
 Demonstrate aggravating factors.
use of  Provide alternative  Improves general
relaxation comfort measures circulation; reduces
skills and (massage, backrub, areas of local
diversional position changes). pressure and
activities as muscle fatigue.
indicated for  Administer  Given to reduce
individual medications as pain or muscle
situation. prescribed by the spasms.
physician.
 Provide emotional  Refocuses
support and attention, promotes
encourage use of sense of control,
stress management and may enhance
techniques. coping abilities.
 Assessment Nursing Diagnosis Planning Implementation Scientific Rationale Evaluation

Risk Factors: Risk for Injury: After 8 hours of  Assess general  This is to After 8 hours of
 Malnutrition Fracture related to nursing status of the determine the nursing
 Physical (e.g., osteoporotic bone intervention, the patient. patient’s intervention, the
broken skin, patient will be able condition that patient was able
altered mobility) to: may cause to verbalize
 Biochemical, injury. different
regulatory  Be free from  Avoid use of  If patients are measures on how
function (e.g., injuries. restraints. Obtain a restrained, they to prevent injury
sensory  Explain physician’s order if can sustain and the patient
dysfunction, methods to restraints are injuries. was free from any
integrative prevent injury. needed. injuries.
dysfunction,  Identify factors  Provide medical  Signs are vital
effector that increase identification for patients at
dysfunction, risk for injury. bracelet for risk for injury.
tissue hypoxia)  Relate intent to patients at risk for
 Decreased hem practice injury.
oglobin selected  Ask family or  This is to
 Developmental prevention significant others prevent the
age measures. to be with the patient from
(physiological,  Increase daily patient to prevent accidentally
psychosocial) activity, if him or her from falling or pulling
feasible. accidentally falling out tubes.
or pulling out
tubes.
 Aid patients sit in a  Patients are
stable chair with likely to fall when
armrests. left in a
wheelchair.
 Use culturally  To prevent
relevant injury occurrence of
prevention injury.
programs
whenever possible.
 Assessment Nursing Planning Implementation Scientific Rationale Evaluation
Diagnosis

 Inability to Impaired After 8 hours of  Assess patient’s  Identifies problems After 8 hours of
move Physical Mobility nursing functional ability for and helps to nursing
purposefully related to bone intervention, the mobility and note establish a plan of intervention, the
within loss as patient will be able changes. care. patient was able
physical evidenced by to:  Provide range of  Helps to prevent to receive
environment, spontaneous motion exercises joint contractures assistance from
including bed fracture  Maintain every shift. and muscle atrophy. the family and the
mobility, functional  Reposition patient  Turning at regular nurse in
transfers, mobility as every 2 hours and intervals prevents performing ADLs
and long as prn. skin breakdown and patient was
ambulation possible within from pressure able to perform
 Inability to limitations of injury. activities to
perform disease  Apply trochanter rolls  Prevents maintain
action as process. and/or pillows to musculoskeletal functional mobility.
instructed  Have a few, if maintain joint deformities.
 Limited ROM any, alignment.
 Reluctance complications  Avoid restraints as  Inactivity created by
to attempt related to possible. the use of restraints
movement immobility as may increase
disease muscle weakness
condition and poor balance.
progresses.  Encourage  Provides
participation in opportunity for
diversional or release of energy,
recreational activities. refocuses attention.
 Instruct family  Prevents
regarding ROM complications of
exercises, methods immobility and
of transferring knowledge assists
patients from bed to family members to
wheelchair, and be better prepared
turning at routine for home care.
intervals.
 Assessment Nursing Planning Implementation Scientific Rationale Evaluation
Diagnosis

 Deformity Imbalanced After 8 hours of  Instruct  Vitamin D aids in After 8 hours of

 Kyphosis Nutrition related nursing recommended daily absorption of nursing
 Loss of to inadequate intervention, the intake for calcium. calcium and intervention, the
height Calcium and patient will be able improves muscle patient was able
 Fractures Vitamin D to: strength. to verbalize
 Low Calcium  Present  Instruct on the  The patient should different ways on
level understanding importance of be outside 15 how to have
of significance adequate exposure minutes daily. proper selection of
of nutrition to to sunlight to prevent foods that is
healing vitamin D deficiency. needed for her
process and  Instruct patient to  Exercise can help condition.
general health. perform gentle build strong bones
 Verbalize and exercises. and slow bone loss.
demonstrates  Provide a balanced  A diet high in
selection of diet. nutrients that
foods or meals support skeletal
that will metabolism: vitamin
accomplish a D, calcium, and
termination of protein.
weight loss.  Limit alcohol intake.  Alcohol may
 Demonstrate decrease bone
behaviors, formation and
lifestyle reduce the body’s
changes to ability to absorb
recover and/or calcium.
keep  Take a nutritional  It may provide more
appropriate history with the accurate details on
weight. participation of the patient’s eating
significant others. habits.