DIAGNOSA

subjective data
patients said pain in the right foot
objective data
p: 1. more pain when moving
2. the current position of the right leg straight in line with the body
Q: pain
R: right leg
S: scale 8
Q: continue

ds: the patient says it can not indulge yourself

do: - patient looks limp
- The patient is attached splint on his right foot
- X-ray results on the discontinuity appears, invisible joint dislocation, seem spur on the calcaneus
- Activity seemed assisted families

ds: - patients said pain post op wound

do: there are stitches on the right leg

problems, acute pain, impaired physical mobility, resti infection

etiology, post-trauma with fracture, fracture cruris, post-op stitches

priority diagnosis
1. based on post-trauma acute pain with fractures
2. impaired physical mobility based fractures of cruris
3. resti based wound infection post-op stitches

PLANNING

NOC

1. After nursing action for hours with 3x24 NOC:

criteria results:
- Reduced pain levels
- No pain response
2. self-care
- Can work independently as eating and toileting
3. the intensity of the skin and mucous membrane tissue well with the expected outcomes:
- Tidfak have allergic reactions to latex (eg no skin lesions or symptoms)
- Recognize and avoid sources of latex in the environment
NIC

1. pain management
2. self-care aids
3. surveillance skin

ACTIVITIES

1. - Assess the level of pain

- Examine the location, character, duration, frequency of pain quality
- Observation of nonverbal cues
-Ajarkanm relaxation breath.
Obtimalkan-use approach for analgesic drug response
- Collaboration analgesic

2. - Assess the activity level of the patient's ability

- Evaluation of the patient's motivation and desire to increase activity
- The patient or family to teach self-care techniques
- Collaboration pain treatment
- Set the position of the patient with the correct body alignment
Support active or passive rom exercises if necessary

3. - Identification of the source of latex that is exposed by a patient either at home or in the
workplace
- Examine the patient and family knowledge about the sources of latex
- Examine the knowledge of sensitization and allergic reactions
- Recommended for self-treatment if you do not have an allergic reaction is suspected
- Psien and teach families about the risk factors of latex allergy

IMPLEMENTATION

1. - Assess the level of pain

- Examines the characteristics of the location / duration, frequency and quality of pain

2 assess the activity level of service

3. monitor for signs and symptoms of infection include vital signs and postoperative state

response

1. p: reduced pain when moving

- Reduced pain at rest
q: patients said pain
r: right leg
s: 8 scale
t: Further
o: grimaced with pain patients seem
a: the problem is not resolved
p: continue intervention

2. s: client says should help others to be able to sit

o: patients seem to look for help when told to sit
a: the problem is not resolved
p: continue intervention

3. s: client says postoperative wound pain

o: - there are stitches on the right leg
- Vital signs:
blood pressure: 120/80 mm Hg
HR: 96 x / min
RR: 22 x / min
T: 36

implementation

1. teach deep breathing relaxation

2. teach patients and families to self-care
2. evaluate the patient's motivation desire to improve activity
3. do wound care with sterile
1.2.3. collaborated analgetik

response
1. s: patient said it is willing to do deep breathing relaxation
o: the patient looks relaxed

2. s: family able to care for her patients say

o: -
2 s: patients say they want to be able to indulge themselves without troublesome family
o: the patient was very keen in the activity but looks less able due to illness

3. s: patient says willing to do the dressing bandaged

o: the patient looks winced in pain

123 s: the patient is willing

o:-2x 1 gram injection cefotaxime
-
-

perform all through the IV injection

EVALUATION

1. S: the patient's right leg say pain is reduced

p:-when moving
q: pain
r: right leg
s: 6 scale
t: continue
O: patients seen in pain during activity
A: the problem is not resolved
Q: continue intervention

2. S: the patient says it can not indulge yourself

O: - patient looks weak
- The patient is attached splint on his right foot
-activity was assisted by family
A: the problem is not resolved
Q: continued intervention

3. S: the patient says it is still pain in the postoperative wound

O: There are stitches on the right leg
A: the problem is not resolved
Q: continued intervention