VII.

NURSING CARE PLAN

Nursing Diagnosis Subjective: Impaired dai ko man physical nahihiro ang mobility related tabay ko, as to loss of verbalized by the integrity of o f patient. bone structures Objective: (fracture) >limited range of motion >slowed movement >limited ability top e r f o r m g r o s s and fine motor > with foam traction at right foot. Assessment Inference Trauma (Vehicular accident) Fracture of the femur bleeding from damaged ends of bone and surrounding tissue stimulates inflammatory response Planning At the end 8 hrs. of NPI the patient will: Intervention Rationale > To identify contributing factors > cause it may restrict movement > to assess functional mobility Evaluation After 8hrs. of NPI, the patient has: a )Verbalized
understanding of the

increased capillary permeability fluid and cellular exudation pain impaired physical mobility

>Determine diagnosis that contributes to immobility. a ) Verbalize > note situations such understanding of the as fractures situation and individual > determine the degree treatment regimen and of immobility in relation safety measures. to suggested scale b ) Participate in ADLs > determine presence and desired activities. of complications related c)Maintain position to immobility of function and skin >Assist client reposition integrity s evidenced self on a regular by absence schedule. of decubitus ulcers d)Maintain a n d increases strength and function > support clients body of affected part. parts using pillows.

> Encourage adequate intake of fluids/ nutritious foods

situation and individual treatment regimen > to assess presence and safety of complications measures. b ) Participatedin > to promote optimum ADLs and desired level of function and activities prevent complications c)Maintained position of function > to maintain position and skin integrity and function and as evidenced by reduce risk of pressure absence of ulcers. decubitus ulcers > It promote well-being d ) M a i n t a i n e and maximizes energy d and increased production strength and function of affected part.

Assessment Subjective: makulog uning nabari ko as verbalized by the patient. Objective: > pain rated as 7
out of 10 >with foam traction at right foot > grimaced face noted, > irritability observed, > restlessness noted > limited range of motion observed

Nursing Diagnosis
Acute pain related to movement of bone fragments secondary to comminuted fracture.

Inference Trauma (Vehicular accident)

Planning At the end 8hrs. of NPI the patient will: a) be able to verbalize

Intervention
> assessment level of pain, location, character, and aggravating factor > Observation for non-verbal cues of pain

Rationale
> to rule out for worsening of underlying conditions and development of complication and prevent occurrence > they may not be congruent with verbal reports and may prompt change in locus of intervention > maximizes use of nonpharmacological techniques for pain relief

Evaluation After 8hrs. of NPI, the patient has: a) Able to verbalize pain relief as evidenced by a pain score of 5 out of 10

Fracture of the clavicle, avulsed & lacerated wounds & abrasions on the skin

pain relief as evidenced by decreased pain score. Long term goal: after 3 days of nursing intervention, the patient will be able to, verbalize and demonstrate techniques that provide pain relief and demonstrate effective use of relaxation techniques as indicated for individual situation

bleeding from damaged ends of bone and surrounding tissue

> Provision of comfort measures as possible such as touch therapy, repositioning, use of cold/heat packs, constant interaction, quiet environment and calm activities > encouragement of usage of relaxation techniques such as focused breathing and imaging > Health teaching about nonpharmacological pain management Collaborative: > Administration of analgesics as to a maximum as needed as indicated by individual situation > referral to occupational/physical therapy program

> to distract patients attention and thus reduce tension > to promote self control and management of pain

stimulates inflammatory response

> to maintain acceptable level of pain

Acute Pain

> to promote active role partcipation and enhanced self-control.