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VII. NURSING CARE PLAN

Assessment Nursing

Diagnosis

Inference Planning Intervention Rationale Evaluation

Subjective:

dai ko man

nahihiro ang

tabay ko, as

verbalized by the

patient.

Objective:

>limited range

of motion

>slowed

movement

>limited ability

top e r f o r mg r o s s and

fine motor

> with foam

traction at right

foot.

Impaired

physical

mobility related

to loss of

integrity of of

bo ne

s t r uc t ur e s

(fracture)

Trauma

(Vehicular accident)

Fracture of the

femur

bleeding from

damaged ends

of bone and

surrounding

tissue stimulates

inflammatoryresponse

increased capillary

permeability

fluid and

cellular exudation

pain

impaired physical

mobility

At the end 8 hrs. of NPI

the patient will:

a ) Verbalize

understanding of the

situation and individual

treatment regimen and

safety measures.

b ) Participate in ADLs

and desired activities.

c)Maintain position

of function and skin

integrity s evidenced

by absenceof decubitus ulcers

d ) M a i n t a i n

a n d increases

strength and function

of affected part.

>Determine diagnosis

that contributes to

immobility.

> note situations such

as fractures

> determine the degree

of immobility in relation

to suggested scale

> determine presence

of complications related

to immobility

>Assist client reposition

self on a regular

schedule.

> support clients body

parts using pillows.

> Encourage adequate

intake of fluids/

nutritious foods

> To identify contributing

factors

> cause it may restrict

movement

> to assess functional

mobility

> to assess presence

of complications

> to promote optimum

level of function and

prevent complications

> to maintain position

and function and

reduce risk of pressure

ulcers.

> It promote well-being

and maximizes energy

production

After 8hrs. of NPI,

the patient has:

a )Verbalized

understanding of the

situation and

individual

treatment regimen

and safety

measures.

b ) Participatedin

ADLs and desired

activities

c)Maintainedposition of function

and skin integrity

as evidenced by

absence of

decubitus ulcers

d ) M a i n t a i n e

d and increased

strength and

function of affected

part.

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Assessment Nursing

Diagnosis

Inference Planning Intervention Rationale Evaluation

Subjective:

makulog uning

nabari ko as

verbalized by the

patient.

Objective:

> pain rated as 7out of 10

>with foam tractionat right foot

> grimaced facenoted,

> irritabilityobserved,> restlessness

noted> limited range ofmotion observed

Acute painrelated tomovement ofbone fragmentssecondary to

comminutedfracture.

Trauma

(Vehicular accident)

Fracture of the

clavicle, avulsed &

lacerated wounds &

abrasions on the

skin

bleeding from

damaged ends

of bone and

surrounding tissue

stimulates

inflammatory

response

Acute Pain

At the end 8hrs. of NPI

the patient will:

a) be able to verbalize

pain relief as evidenced

by decreased pain score.

Long term goal:

after 3 days of nursingintervention, the patientwill be able to, verbalize

and demonstratetechniques that provide

pain relief anddemonstrate effective useof relaxation techniques

as indicated for individualsituation

> assessment level of pain,

location, character, andaggravating factor

> Observation for non-verbal

cues of pain

> Provision of comfort

measures as possible suchas touch therapy,repositioning, use ofcold/heat packs, constantinteraction, quiet environmentand calm activities> encouragement of usage of

relaxation techniques such asfocused breathing andimaging> Health teaching about non-

pharmacological painmanagement

Collaborative:

> Administration of analgesics

as to a maximum as neededas indicated by individualsituation

> referral tooccupational/physical therapyprogram

> to rule out for worsening of

underlying conditions anddevelopment of complicationand prevent occurrence> they may not be congruent

with verbal reports and mayprompt change in locus ofintervention

> maximizes use of non-

pharmacological techniquesfor pain relief

> to distract patients

attention and thus reducetension

> to promote self control and

management of pain

> to maintain acceptable

level of pain

> to promote active role

partcipation and enhancedself-control.

After 8hrs. of NPI,

the patient has:

a)Able to verbalize

pain relief as

evidenced by a

pain score of 5

out of 10