1. Carry out the doctor's order (e.g.
kardex, meds chart, tickets)
NURSING DIAGNOSIS: Acute pain r/t movement of bone fragments, edema, and injury to the soft tissue.
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE CUES: At the end of 8 hours of student INDEPENDENT: At the end of 8 hours of student
“Sakit kayo Ma’am di ko nurse – client interaction, there nurse – client interaction, the
ganahan mulihok” As will be relief of pain as 1. Monitor patient’s pain using Pain assessment determines goal was:
evidenced by: COLDSPA the effectiveness of
verbalized by the patient
1. Client will verbalize relief of interventions. Many factors, 1. Partially met- Patient’s level of
pain, pain scale of 1-3 out of including the level of pain reduces into 4/10.
OBJECTIVE CUES:
10. anxiety, may affect the
perception of pain. 2. Partially met- Patient was
Weakness noted slightly relaxed
2. Client will display relaxed
Pain scale of 9/10 2. Maintain immobilization of Immobilization relieves pain
manner.
Presence of facial grimace affected part using bed rest, and prevents bone
cast (if indicated) 3. Met-patient was attentive and
Discomfort was observed displacement and extension willing to participate on the
3. Client will demonstrate of tissue injury. activities and procedures that
Vital Signs: ability to participate in should be done.
activities with minimal 3. Elevate and support injured Promotes venous return,
Temperature: 36.9 OC extremity.
complaints of discomfort. decreases edema and may 5. Met-patient shows
Pulse Rate: 85 bpm
reduce pain. demonstration of relaxation
Respiratory Rate: 18 4. Client will demonstrate use skills and diversional
cpm of relaxation skills and 4. Elevate bed covers; keep Maintains body warmth
linens off toes. activities as indicated for
Blood Pressure: 100/70 diversional activities as without discomfort due to individual situation.
mmHg indicated for individual the pressure of bedclothes on
situation. affected parts.
5. Explain procedures before
Allows the patient to prepare
starting them.(ORIF plating,
tibia right, closed reduction, mentally for activity and to
application of cast) participate in controlling the
level of discomfort.
6. Perform and supervise active
and passive ROM exercises. Maintains strength and
mobility of unaffected
muscles and facilitates
resolution of inflammation in
injured tissues.
7. Provide alternative comfort
measures (massage, Improves general
backrub, position changes, circulation; reduces areas of
deep breathing) local pressure and muscle
fatigue.
DEPENDENT:
8. Administer Medication as
prescribed, ketorolac Injectable and oral
(Toradol) for bone pain. nonsteroidal anti-
inflammatory drugs
(NSAIDs): ketorolac . Given
to reduce pain or muscle
spasms. Administer
analgesics around the clock
for 3–5 days. Studies of
ketorolac (Toradol) have
proven effective in
alleviating bone pain, with
longer action and fewer side
effects than narcotics agents.
NURSING DIAGNOSIS: Impaired Physical Mobility r/t neuromuscular skeletal impairment; discomfort; restrictive therapies as evidenced by
inability to move purposefully within the physical environment
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE CUES: At the end of 8 hours of INDEPENDENT: At the end of 8 hours of student
“Maglisod kog lihok Ma’am student nurse – client nurse – client interaction, the
agi sa akong condition” As interaction, there will be 1. Assess the degree of immobility The patient may be restricted by goal was:
improved physical mobility as produced by injury or treatment self-view or self-perception out
verbalized by the patient
evidenced by: and note the patient’s perception of proportion with actual 1. Met- patient shows relief of
1. Client will show relief of of immobility. physical limitations, requiring discomfort and absence of
OBJECTIVE CUES: restlessness observed.
discomfort and restlessness information or interventions to
promote progress toward
Discomfort was observed 2. Partially met- patient maintains
2. Client will maintain wellness.
Restlessness position of function slightly.
position of function.
Limited range of motion 2. Monitor blood pressure (BP) Postural hypotension is a
with the resumption of activity. common problem following 3. Partially met- after treatment
3. Client will increase Note reports of dizziness. prolonged bed rest and may and therapy patient slightly
Vital Signs: strength/function of require specific interventions (tilt increases strength/function of
Temperature: 36.9 OC affected and compensatory table with gradual elevation to affected and compensatory
Pulse Rate: 85 bpm body parts. the upright position). body parts.
Respiratory Rate: 18 cpm 4. Client will demonstrate 3. Encourage the use of isometric Isometrics contract muscles
exercises starting with the 4. Met- Patient demonstrates
Blood Pressure: 100/70 techniques that enable without bending joints or moving techniques that enable
mmHg resumption of activities. unaffected limb. limbs and help maintain muscle resumption of activities.
strength and mass.
4. Provide footboard, wrist splints, Useful in maintaining a
trochanter, or hand rolls as functional position of
extremities, hands, and feet and
appropriate. preventing complications
(contractures, foot drop).
Prevents or reduces the incidence
of skin and respiratory
5. Reposition periodically and complications (decubitus,
encourage coughing and deep- atelectasis, pneumonia).
breathing exercises.
Effective pain intervention will
enhance the patient’s ability to
engage in appropriate activity
6. Teach the patient and significant and exercises.
others (SO) about the use of
analgesics and instruct
nonpharmacological pain
management such as imagery,
relaxation, and distractions.
Useful in creating individualized
COLLABORATION: activity and exercise programs.
The patient may require long-
Consult with a physical, term assistance with movement,
occupational therapist, or strengthening, and weight-
rehabilitation specialist. bearing activities.
Consult with a nutritionist to In the presence of
provide a diet high in proteins, musculoskeletal injuries,
carbohydrates, vitamins, and nutrients required for healing are
minerals, limiting protein content rapidly depleted, often resulting
until the first bowel movement. in a weight loss of as much as 20
to 30 lb (9kg to 13 kg) during
skeletal traction. This can have a
profound effect on muscle mass,
tone, and strength.
NURSING DIAGNOSIS: Risk for Fall r/t loss of skeletal integrity (fractures in tibia/fibula right)
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE CUES: At the end of 8 hours of student INDEPENDENT: At the end of 8 hours of student
“ Maglisod kog lihok nurse – client interaction, Risk 1. Maintain bed rest or limb Provides stability, reducing nurse – client interaction, the
Ma’am dayun mahadlok ko for fall is eliminated and safety rest as indicated. Provide the possibility of disturbing goal was:
basin mahulog ko sa measures were maintained as support of joints above and alignment and muscle
evidenced by: below the fracture site, spasms, which enhances 1. Met- patient shows relief of
higdaanan Ma’am” As
especially when moving and healing. discomfort and absence of
verbalized by the patient 1. Relief of dizziness or turning. lightheadedness
lightheadedness
OBJECTIVE CUES: 2. Secure a bed board under A soft or sagging mattress 2. Met-Patient was able to
the mattress or place the may deform a wet (green) maintain stabilization and
dizziness or lightheadedness. 2. Client will maintain patient on the orthopedic plaster cast, crack a dry alignment of fracture(s).
Limited range of motion stabilization and alignment bed. cast, or interfere with
Vital Signs: of fracture(s). traction pull.
Temperature: 36.9 C O 3. Partially met- Patient
3. Support fracture site with Prevents unnecessary demonstrates body
Pulse Rate: 85 bpm 3. Client will demonstrate body pillows or folded blankets. movement and disruption of mechanics that promote
Respiratory Rate: 18 mechanics that promote Maintain a neutral position alignment. Proper stability at the fracture site.
cpm stability at the fracture site. of the affected part with placement of pillows also
Blood Pressure: 100/70 sandbags, splints, trochanter can prevent pressure
mmHg roll, footboard. deformities in the drying
cast.
4. Review follow-up and serial
X-rays. Provides visual evidence of
proper alignment or
beginning callus formation
and healing process to
determine the level of
activity and need for
changes in or additional
therapy.
5. Position the patient, so that Promotes bone alignment
appropriate pull is and reduces the risk of
maintained on the long axis complications (delayed
of the bone and provide healing and
health teaching about proper nonunion).Body mechanics
body mechanics. promotes stability at the
fracture site
1. Carry out the doctor's order (e.g. kardex, meds chart, tickets)
2. Carry out the doctor's order (e.g. kardex, meds chart, tickets)
