Cues Nursing Nursing Nursing Nursing Rationale Evaluation
Diagnosis Analysis Objectives Interventions
P-Acute pain After 15-30 minutes of Independent Goal MET as avidenced
Subjective: E-Related to feacture, VEHICULAR delivering appropriate >Assess type and >Pain is expected after fracture, by:
soft tissue damage and ACCIDENT nursing intervention location of patient’s soft tissue damage and muscle Patient verbalizes
“Masakit pa rin kung muscle spasm the patient will pain. spasm contribute to discomfort, comfort and relief of
nahihila bigla” S- As evidenced by verbalized a relief of pain on subjective and is pain. The pain scale of 7
As verbalized by the >Reports of pain pain, pain scale of 7 evaluated through description of reduces to 5.
patient >Pain scale of 6 out of will be reduce to 5. characteristics and location which Appears comfortable
10 The patient will are important in determining and relaxed and able to
Objective: >Weak in appearance Strong force causes display a relaxed cause of discomfort and for participate activities,
>Pain scale of 6 out >Distraction noted femoral fracture and manner and able to proposing interventions. sleep/rest appropriately.
of 10 >Narrowed focus muscle spasm partcipate in activities, >Acknowledeg >Reduces stress experienced by
>Distraction noted >Presence of facial mask sleep/rest existence of pain; inform the
>Narrowed focus of pain appropriately. patient of available communicating concern and
>Presence of facial >With Protective and analgesics; record availability of help in dealing
mask of pain guarding behavior Damage bone nerve patient’s baseline with pain. Documentaion
>With Protective and >With sleeping ending discomfort. provides baseline data.
guarding behavior Disturbance noted
>With sleeping >Handle the affect >Movement of bone fragments is
Disturbance noted Prostaglandin extremity gently painful; muscle spasms occur
stimulation supporting it with hands with movement; adequate support
or pillow. diminishes soft tissue tension.
>Use pain modifying >Pain perception can be
Increased strategies: diminished by distraction and
prostaglandin ar refocusing of attention.
damage site
a. Modify the a. Interaction with others,
environment. distraction and environemntal
stimuli may modify pain
CNS perception experiences.
b. Administer prescribed b. Analgesics reduces pain,
Acute pain analgesics. muscle relaxants may be
prescribed to decrease discomfort
associated with muscle spasm.
c. Encourage patient to
use pain relief measures c. Mild pain is easier to control
before pain is than severe pain.
unbearable.
d. Evaluate patient’s d. Assessment of effectiveness
response to medications measures provides basis for future
and other pain reduction management interventions.
techniques.
e. Consult with e. Change in treatment plan may
physician if relief of be necessary.
pain is not obtained.
>Position for comfort >Alignment of body facilitates
and function. comfort; positioning for function
diminishes stress on
musculoskeletal system.
>Assist with frequent >Change in position relieves
changes in postion. pressure and associtred
discomfort.
>Maintain
immobilization of >Relives pain and prevents bone
affected part by means dsplacement/extention of tissue
of bedrest, cast splint, injury.
traction.
>Elevated and support >Promotes venous return,
injured extremity. decreses edema may reduce pain.
>Avoid use of plastic >Can increase discomfort by
sheets pillows under enhancing heat production in
limbs in cast. drying cast.
>Elevate bed covers, >Maintains body warmth without
keep linens off toes. discomfort due to pressure of
bedclothes on affected parts.
>Perform and supervise >Maintain strength, mobility of
passive ROM exercises. unaffected msucles and facilitates
resolution of inflammation in
injured tissues.
>Provide aternative >Improves genaral circulation,
comfort measures reduces areas of local pressure
(massage, back rub or and muscle fatigue.
position changes).
>Provide emotional >Refocuses attention, promotes
support and encourage sense of control and may enhance
use of stress coping abilities in the
management techniques management of the stress of
(progressive relaxation, traumatic injury and pain which is
deep breathing likely to persist for an extended
exercises, guided period.
imagery)
>Identify diversional >Prevents boredom, reduces sucle
activities appropriate fro tension and can increase muscle
client age, physical strength ; may enhnace coping
abilities and personal abilities.
preferences.
>Investigate any reports >May signal devloping
of unusual pain or deep complications.
progressive and poorly
localized pain unrelieved
by analgesic.
Collaborative
>Apply cold pack first >Reduces edema and hematoma
24-72 hours and as formation, decreases pain
necessary. sensation.
>Administer >Given to reduce pain and muscle
medications as spasms.
indicated.
>Mantain continuous >Optimal pain magement is
patient-controlled essential to permit early
analgesic using mobilization and physical
peripheral epidural, theraphy and to maintain
intrathecal routes of adequate blood level of analgesia
administration. preventing fluctuations in pain
relief with associated muscle
tension or spasms.
Subjective: P-Impaired physical Vehicular accident After 4 hours of >Asses degree of >Client may be restricted by self- Goal PARTIALLY MET
mobility ralted to pain rendering appropriate immobility produced by percepltion out of proportion wit as Evidenced by:
“Nahihirapan na nga and discomfort and nursing interventions, injury/treatment and actual physical limitations
ako, gusto ko nang physiologic immobility the client will improve note client’s perception requiring interventions to The patient identify
maglakad” E-Pain and discomfort muscle strength and of immobility. promote progress toward some ways in improving
As verbalized by the and physiologic do some range of wellness. muscle strength and
patient immobilty Strong force causes motions on the >Encourage >Provides opporunity for release done some range of
S-As evidenced By: femoral fracture and extremities to prevent participation in of energy, refocuses attention, motions on the
muscle spasm atrophy and will diversional/recreational enhances client’s sense of control extremities and
>Inability to move >Inability to move demonstrate actvities. Maintain and aids in reducing social demonstrated some
purposefully purposefully techniques that enable stimulating isolation. techniques that enable
>Reluctant to move >Reluctant to move resumption of environment; e.g., radio, resumption of activities
freely freely Damage bone nerve activities of daily TV, newspapers, of dailyliving.
>Limited ROM >Limited ROM ending living personal
>Decreased muscle >Decreased muscle possesions/pictures,
strength and control strength and control clock Calendar visits,
>Unable to walk. >Unable to walk. Impaired Physical from family/friends.
>With fair skin. >With fair skin. Immobilty
>With Steinmann pin >With Steinmann pin >Instruct client in/assist >Increases blood flow to muscles
inserted at proximal inserted at distal 3rd of with active/passive and bone to improve mescle tone
3rd of the femur(BST) the femur(BST) ROM exercises of and maintain joint mobility,
>No signs of swelling >No signs of swelling at affected and unaffected prevent contractures and atrophy
at Steinmann pin site Steinmann pin site extrimities. and calsium resorption from
>Needs assistance in >Needs assistance in disuse.
doing ADL’s. doing ADL’s.
>Enourage of isometric >Isometrics contract muscles
exercises starting with without bending joints or moving
the unaffected limb. limbs and help maintain muscle
strength and mass.
>Provide footboard, >Useful in maintaining functional
wrist splints, position of extremities, hands/feet
trochanter/hand rolls as and preventing complications.
appropriate.
>Place in supine >Reduces risk of flexion
position periodically if contracture of femur.
possilble when traction
is used to stabilized
lower limb fractures.
>Instruct in/encourage >Faciliates movement during
use of trapeze and hygiene/ skin care and linen
“position” for lower changes, reduces discomfort of
limb fractures. remaining flat in bed. Post
position involves placing the
injured foot flat on the Bed with
the knee bent while grasping the
trapeze and lifting the body off
the bed.
>Assist with/encourage >Improves muscle strength and
sel care activities (e.g., circulation, enhances client
bathing, shaving) control in situation and promotes
self-directed wellness.
>Monitor blood pressure >Postural hypostension is a
with resumption of common problem following
activity. Note reports offollowing prolonged bedrest and
diziness. may require specific interventions
(gradual elevation to upright
position).
>Reposition periodically >Prevents and reduces incidence
and encourage coughing of skin and respiratory
or breathing exercices. complications.
>Auscultate bowel >Bed rest, use of analgesics and
sunds. Monitor changes in dietary habits can slow
elimination habits and peritalsis and produce
provide for regular constipation. Nursing measures
bowel routine. Place on that facilitate elimination may
bedside commode, if prevent complications.
feasible, or use fracture
pan. Provide privacy.
>Perform a thorough >Provides baseline fro
assesment of client’s comparsion with postsurgical
prior to bowel habits. concerns. Constipations in
orthopedic clients is a major issue
and needs immediate and ongoing
attention.
>Encourage increased >Keeps the body well hyfarted,
fluid inatke to 2000- decraesing risk of urinary
3000 mL/day. infection, stone formation and
helps prevent constipation.
>Provide diet in high in >In the presence of
proteins, carbohydrates, musculoskeletal injuries, early
vitamins and minerals, good feeding is needed as
limiting proein content nutrients required for healing are
until after first bowel rapidly depleted. This can have a
movement. profound effect on muscel mass,
tone and strength. Protein foods
increase contents in small bowel,
resulting in gas formation and
constipation. Therefore,
gastrointestinal functio should be
fully restores before protein foods
and increased.
>Increase the amount of >Adding bulk to stool helps
roughage/fiber in the prevent constipation. Gas forming
diet. Limit gas forming foods can cause abdominal
foods. distention especially in presence
of decreased intestinal mobility.
Collaborative:
>Consult with >Used in creating aggressive
physical/occupational individulaized activity program.
therapist and/or Client may require log term
rehabilitation specialist. assistance with movement,
strengthening and weight-berang
activities as well as use of
adjuncts.
>Refer to >Clients with fractures especially
dietitian/nutrition team when associated withtraumay
as indicated. may have special nutrional
considerations to maximize
healing of bones and tissues.
>Initiate bowel >Important to promote regular
program(stool softeners, bowel evacuation and prevent
enemas,laxatives) as constipation.
indicated.
>Refer to psychiatric >Client may require mre intensive
clinical nurse treatment to delay with reality of
specialist/therapist as current condition, prolonged
indicated. immoboility, percoieved loss of
control.
