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Patient Assessment: Pain and Mobility Issues

The patient has a right leg fracture causing acute pain, impaired mobility, and low self-esteem. Objective findings include vital signs within normal limits and guarding behavior. The patient verbalizes pain with movement and fatigue from prolonged bedrest, inability to perform usual activities, and anxiety about the leg injury. Potential problems include risk of infection, sleep disturbances from pain, impaired parenting from mobility issues, falls from weakness, loneliness from isolation, and poor coping from a change in body image.

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itsmeaya
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7 views2 pages

Patient Assessment: Pain and Mobility Issues

The patient has a right leg fracture causing acute pain, impaired mobility, and low self-esteem. Objective findings include vital signs within normal limits and guarding behavior. The patient verbalizes pain with movement and fatigue from prolonged bedrest, inability to perform usual activities, and anxiety about the leg injury. Potential problems include risk of infection, sleep disturbances from pain, impaired parenting from mobility issues, falls from weakness, loneliness from isolation, and poor coping from a change in body image.

Uploaded by

itsmeaya
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

CUES

SUBJECTIVE:
>Hindi lang
paghikapa akon tiil
kay kasakit. As
verbalized by the
patient.

PHYSIOLOGIC

BEHAVIORAL

PROBLEM
S

ACTUAL

POTENTIAL

ACTUAL

POTENTIAL

Acute Pain

Impaired skin
integrity r/t tissue
trauma 2 right leg
fracture

Risk for infection r/t


tissue trauma 2 right leg
fracture

Impaired comfort r/t


acute pain

Risk for disturbed sleep pattern:


insomnia r/t physical discomfort

Anxiety r/t changes in


role function

Risk for Alteration in role


performance: parenting role r/t
altered body function

>Facial grimace
noted
>Guarding behavior
noted
>Irritability noted
OBJECTIVE:
Vital signs
taken:
BP: 110/80 mmHg
RR: 19 cpm
PR: 69 bpm
Temp: 64.4 C
Body
Weakness
SUBJECTIVE:
>Nakapoy nko sige
higda, di ko mayo ka
gihogiho tungod sang
tiil ko.

Impaired physical
mobility r/t decreased
muscle strength

Risk for injury: fall r/t


altered body function

>Irritability noted

OBJECTIVE:
Vital signs
taken:
BP: 110/80 mmHg
RR: 19 cpm
PR: 69 bpm
Temp: 64.4 C

SUBJECTIVE:
>Kalain na lantawon
sang tiil ko.
>Anxiety noted
OBJECTIVE:
Vital signs
taken:
BP: 110/80 mmHg
RR: 19 cpm
PR: 69 bpm
Temp: 64.4 C

Low selfesteem

3
Disturbed body image
r/t trauma

Risk for loneliness r/t


physical isolation

Deficient diversional
activity r/t skeletalmuscular impairment

Ineffective coping r/t change in


body part

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