Nursing Care Plan
OPEN REDUCTION INTERNAL FIXATION
In Partial Fulfilment of the
Requirements in NCM-212 RLE
SURGERY ROTATION
Submitted to:
Josephine Magno, RN, MN
Clinical Instructor
Submitted by:
Janiel Kayyi D. Torralba, St.N.
BSN 3E GROUP 1
December 6, 2021
SCENARIO:
o Junallou Fernandez an 18 year old gymnast attained a severe wrist injury on her right hand during training. Due to immense pain and immobility on her
hand she was brought to the hospital. Upon arriving to the emergency room, the staff initially assessed her with vital signs of BP=130/95, RR=33 cpm, HR=
130, PR=128, TEMP= 37.6 C, and Pain scale of 10/10. The doctor ordered a stat x-ray after physically examining her. When the results came, Dr. Sanchez
declared a right Distal Radial fracture. After the obtainment of clearances and consents she was sent to the Operating Room to repair the fracture through an
Open Reduction Internal Fixation. Junallou was taken to the recovery room following the operation, when she awoke she verbalized pain on her right wrist
“Sakit ako wrist…ngolngol siya”, “Gusto raman unta nako e adjust ang pwesto sa ako kamot aron dili masandigan o madat-ugan, pero musakit jud siya”,
“Sakit lihikon ako kamot pero kinahangalan aron di nako siya matandog pero mas musakit siya kung tistingan nako ilihok”, “Wa nako kahibaw unsaon kay
sakit sad sa lawas if mu pundo rako sa isa ka posisyon”, “Di jud nako siya malihok kay sakit”, “Tungod kaha sa metal plate ug screws ang sakit na ako gibati
karon o sa incision sa ako wrist kay nihubag man gud siya niya ngolngol?”. Upon assessment there was swelling, redness, tenderness, and immobility on
the operation site and verbalized a pain scale of 6/10 when the hand is resting but when attempting to adjust position it becomes 8/10. Her vital signs are
BP= 125/85, RR= 20 cpm, HR= 110 bpm, PR= 108 bpm, TEMP= 37 C.
CLUSTERING OF CUES:
SELF-PERCEPTION/SELF- NUTRITIONAL-METABOLIC ELIMINATION PATTERN ROLES/RELATIONSHIP HEALTH PERCEPTION –
CONCEPT PATTERN PATTERN PATTERN HEALTH MANAGEMENT
“Lain akoang paminaw PATTERN
kanang kapoy kaayo…bisan Crohn’s Disease of
wala koy gibuhat kay hawoy the Ileum
na di ko makalihok.”
”Nag sige gihapon ko ug
kalibanga.”
“Mahadlok ko mukaon
kay basi di muundang ako
kalibanga kung mag sige
sad kog kaon.”
Name of Patient: Junallou Fernandez Age: 18 years old Sex: Female Attending Physician: Dr. Sanchez Ward: St. Catherine
Chief Complaint: Pain and wrist immobility Diagnosis: Distal Radial Fracture
DATE NURSING DIAGNOSIS
& CUES NEEDS PATIENTS INTERVENTIONS IMPLEMENTATIONS EVALUATION
TIME OUTCOME
“Sakit ako C Pain related to post- Within the 8-hour INDEPENDENT:
7AM wrist… O operational open reduction span of care the Assess and record 1 3PM
ngolngol siya” G internal fixation surgery of patient will be able level of pain
“Gusto raman N wrist fracture as evidenced by to: experienced.
unta nako e I pain, inflammation, redness, R: Assess intensity of Janiel Kayyi
adjust ang T slight immobility on operation a. Verbalize pain pain that may affect vital D. Torralba,
pwesto sa ako I site, and slightly elevated relief by a pain signs, emotions, and St,N.
kamot aron dili V blood pressure and heart rate scale of 3/10 behavior by Wong-Baker
2
masandigan o E associated with right distal or lower. FACES pain rating scale,
madat-ugan, - radial fracture. b. Move their Visual Analog Scale, and
pero musakit P right hand with Face Legs Activity Crying
jud siya” E Rationale: minimal or no Consolability Scale.
“Sakit lihikon R Open Reduction Internal pain or Determining pain also
ako kamot C Fixation (ORIF) treats discomfort by assesses effectiveness
pero E seriously fractured bones with not displaying of interventions.
kinahangalan P hardware (metal plates, rods, facial grimace 3
aron di nako T pins, and screws) to re-align and no Encourage the
siya matandog U and mend the bones together verbalized verbalization of
pero mas A (Nunez. 2019). Although ORIF complaints. problems related to
musakit siya L reduces the immense pain of c. Display a the injury.
kung tistingan the fracture, post-surgery will relaxed aura R: Aids alleviate the
nako ilihok” P still manifest pain, redness, through patient’s anxiety and
“Wa nako A and inflammation due to the moving their questions that may help
kahibaw kung T incision and installed hand without the nurse determine the
T hardware (Healthline, 2018). discomfort or right interventions.
mupuyo ra ko E The pain experienced causes pain and 4
kay sakit sad R electric signals to trigger the verbalizing Maintain
sa lawas if mu N sympathetic nervous system, relief. immobilization of
pundo rako sa then stimulate the central wrist through bed
isa ka nervous system, causing the rest, cast, or splint.
posisyon” release of adrenalin and R: Immobilization of the
“Di jud nako cortisol, which elevates blood affected body part
5
siya malihok pressure and heart rate relieves pain, prevents
kay sakit” (Tennant, 2021). bone displacement, and
“Tungod kaha possible extension of
sa metal plate tissue injury. 6
ug screws ang
sakit na ako Elevated and place
gibati karon o support upon the 7
sa incision sa injured body part.
ako wrist kay R: Promotes venous 8
nihubag man circulation thus
gud siya niya decreasing edema and
ngolngol? reducing pain.
(As verbalized by 9
the patient) Avoid using plastic
sheets and pillows 10
Objective: under the affected
Pain Scale: body part.
o 6/10 = hand R: Plastic bed linens
is resting but increase discomfort by
when enhanced production of
o 8/10 = heat.
attempting to
adjust Explain procedures to
position the patient before
Facial grimace initiating them.
when in pain R: Allows the patient’s
Swelling on mental prepapration for
surgical site any
Redness on
surgical site Provide proper oral
hygiene.
Tenderness on
R: A clean mouth
surgical site enhances the taste of
Slight food (Vera, 2020).
Immobility on
right hand Serve meals in well-
Vitals Signs: ventilated and
o BP= 125/85 pleasant
mmHg surroundings with
o PR= 108 unhurried
bpm atmosphere and
o HR= 110 congenial company.
bpm R: A pleasant dining
environment aids in the
reduction of stress (Vera,
2020).
Avoid foods that
might cause or
worsen abdominal
cramping, flatulence
such as milk
products, foods high
in fiber or fat, alcohol,
caffeinated
beverages,
chocolate,
peppermint,
tomatoes, orange
juice, and spicy
foods.
R: Food tolerances vary
per person, depending
on the stage of disease
and area of GI track
affected (Vera, 2020)
Record food intake
and if there a
changes in the
symptomatology.
R: Evident in identifying
specific nutrient
deficiencies and
determining GI response
to food (Vera, 2020).
Encourage the
patient to verbalize
concern toward diet
resumption.
R: The fear that food
intake will cause
exacerbation of
symptoms may lead to
hesitation (Vera, 2020).
Encourage patient to
drink plenty of fluids;
drink small amounts
of water throughout
the day around 8-12
glasses.
R: Chronic diarrhea can
cause dehydration,
which can lead to feeling
of weakness and fatigue
(Conaway, 2020).
Encourage patient to
eat 4-6 small meals
daily or snack every 3
to 4 hours.
R: Reduces meal size to
help ease the symptoms
of Crohn’s Disease
(Konkel, 2021).
Provide information
and importance on
food allowed for
Crohn’s Disease.
R: Proper nutrition is
beneficial for promoting
overall health and well-
being as CD can cause
serious complications,
including nutrient
deficiencies, weight loss,
and malnutrition (Crohn’s
& Colitis Foundation,
2021).
Provide a cool, quiet,
and dark environment
conducive for rest.
R: Having adequate
sleep and taking naps
during the day ( Fairview
Health Services, 2019)
helps cellular restoration
by repair and regrowth
(Lamoreux & Nunez,
2020).
DEPENDENT:
If health care provider
indicates, keep
patient NPO.
R: Resting the bowel
decreases intestinal
peristalsis and diarrhea
as well as limiting
malabsorption and
nutrient loss (Vera,
2020).
Resume or advance
diet as indicated by
health care provider
(clear liquids
progressing to bland,
low residue; then
high-protein, high-
calorie, caffeine-free,
non-spicy, and low-
fiber as indicated).
R: Allow the intestinal
tract to readjust to the
digestive process. The
consumption of protein
aids in tissue repair, and
food taken in small
amounts decreases
peristaltic response
(Vera, 2020).
Provide medications
such as iron,
multivitamin, and
mineral supplements
as ordered by health
care provider.
R: Help alleviate
malnutrition and treat
anemia to reduce fatigue
from decreased red
blood cell count that
limits oxygen amount
carried through the
body’s tissues
(DiGiacinto & Murphy,
2021).
Provide anti-diarrheal
drugs for Crohn’s
Disease as ordered
by health care
provider.
R: Diarrhea is one of the
unsettling and
bothersome symptoms of
CD that disrupt ADL
(Faris, 2019).
COLLABORATIVE:
Promote patient
participation in
special dietary
planning.
R: Provides the patient
sense of control and
opportunity to select
desired foods that may
aid in increased food
intake (Vera, 2020).
Discuss with patient
the short and long
term nutrition and
weight goals from a
created daily weight,
and food and fluid
chart.
R: Effectively monitors
patient’s daily nutritional
intake and progress in
weight goals
(Nursestudy.net, 2021).
Encourage patient to
seek aid from a
Dietician who
specializes in Crohn’s
Disease.
R: Provides a more
individualized care when
it comes to diet and
nutrition (Nursestudy.net,
2021).
REFERENCES:
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cancer/coping/physically/fatigue/how-fatigue-assessed
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disease/diet-nutrition
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tool/anemia
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