St.
Anthony’s College
                                                                                         San Jose, Antique
                                                                                         Nursing Department
    NAME: X.M.
    AGE: 37years old
    Dr.: Dr.A.
    CC:     V.A.                                                     NURSING CARE PLAN
        CUES                 NURSING               RATIONALE                    PLANNING                 INTERVENTION                  RATIONALE                      EVALUATION
                            DIAGNOSIS
SUBJECTIVE:                                     Fractures occur when       GENERAL:                   INDEPENDENT:
“budlayan ako             Impaired physical     the bone is subjected      After 8 hours of                                                                   After 8 hours of rendering
magtindug” as             mobility, inability   to stress greater that     rendering appropriate                                                              appropriate nursing
verbalized by the         to stand alone        it can absorb. When        nursing interventions                                                              interventions the patient was
patient                   related to skeletal   the bone is broken,        the patient will be able                                                           able to:
                          impairment to         adjacent structures        to:
                          facture of the 2nd    are also affected,         1. Demonstrate             -assist patient to do        -to improve muscle            1. Demonstrate
                          metatarsal at left    resulting in soft tissue       increasing function    active ROM exercises on      strength and joint               increasing function of
                          foot and left         edema, hemorrhage              of the extremities     the lower extremities        mobility.                        the extremities.
OBJECTIVE                 shoulder              into the muscles and                                                               (GULANICK &
-received patient lying                         joints, joints                                                                     MYERS:2007, p. 127)
on bed, awake,                                  dislocations, ruptured                                                                                           2. Regain or maintain
coherent, & responsive:                         ten-dons, severed                                                                                                   mobility at the highest
                                                nerves, and damaged                                                                                                 possible level.
-grimace face noted                             blood vessels. Body
                                                organs maybe injured                                  DEPENDENT:
- limited ROM                                   by the force that                                     -administer analgesics       -in order for the muscle      3.    Verbalize
                                                caused the fracture                                   such as Tramadol             to be more relax and               understanding of the
V/S                                             fragments. After a                                    (Tramal) as prescribed       relieve the pain                   situation /risk factors,
• BP: 120/80mmHg                                fracture, the                                         by the physician.            (GULANICK &                        individual therapeutic
• T : 37°C                                      extremities cannot                                                                 MYERS:2007, p. 127)                regimen and safety.
• PR : 77 bpm                                   function properly                                     COLLABORATIVE:
• RR : 19cpm                                    because normal                                        - consult with physical or   -to develop individual             -Goal was partially met
 02sat:97                                      functions of muscle                                   occupational therapist       exercise or mobility
                                                depend on the                                         as indicated.                program and identify
                                                integrity of the bones                                                             appropriate adjunctive
                                                which they are                                                                     devices.
                                                attached. (Gulanick                                                                (GULANICK &
&Myers: 2007, p.126)                                                       MYERS:2007, p. 129)
                                                INDEPENDENT
                       2. Regain or maintain    -assess degree of          -patient may be
                          mobility at the       mobility produced by       restricted by self-view
                          highest possible      injury or treatment and    or self- perception out
                          level                 note patient’s             of proportion with
                                                perception of immobility   actual physical
                       3. Verbalize                                        limitations requiring
                          understanding of                                 interventions to
                          the situation /risk                              promote progress
                          factors, individual                              toward wellness.
                          therapeutic                                      (GULANICK &
                          regimen and safety                               MYERS:2007, p. 127)
                          measures