Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide Nursing assessment for contractures: • Check pain levels and medicate prior to full assessment • If patient is comfortable, assess range of motion, strength, and ambulatory ability; check ability to transfer and use assistive devices; evaluate ability to perform ADLs; look for shortened muscles over the joint areas • Inquire about history behind immobility: paralysis, coma, arthritic condition, or any other condition that causes immobility • Inquire if patient has had any physical therapy, splinting, and care in the home for mobility • Review radiology reports: x-ray Nursing diagnosis for contractures: • Pain related to muscle stiffness and joint contractures • Impaired physical mobility related to neurologic/musculoskeletal disorder • Self-care deficit related to immobility and pain • Risk for ineffective management related to knowledge deficit, contracture care, and prevention Nursing interventions for contractures: • Assess for pain frequently and medicate per MDorder • Refer to physical therapy for splint application and therapy plan • Give good skin care to prevent breakdown • Perform range of motion exercises to prevent muscle spasms andshortening • Maintain proper body alignment and position with pillows, changing the position often • Place splints on patient every day • Use footboard for feet (plantar flexion) to prevent foot drop • Provide frequent rest periods and pace activities; encourage self-care as tolerated • Provide a diet high in nutrition, calories, and fiber to provide for extra energy needs • Teach the patient and family about pain relief: heat, massage, stretching, active and passive range of motion exercises Expected outcomes for contractures: • Patient demonstrates/verbalizes increased comfort and pain relief • Patient able to perform ADLs within limits of ability with no further decline • Patient and family show compliance with splint application and range of motion exercises • Actively participates in physical therapy sessions • Patient and family verbalize an understanding of the condition and treatment plan

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