NURSING CARE PLAN 1 Cues

Date: 01 07 13 Time: 9:30 am Subjective: Dili naman kayo sakit akong tiil as verbalized with PS: 4/10. Objective: Guarding behavior noted Restlessness noted With presence of elastic bandage left leg noted.

Need

Nursing Diagnosis
Acute pain related to presence of injury left lower extremities 2 vehicular accident.

Objective

Nursing Interventions
Establish rapport.

Rationale
To gain trust and cooperation. To have a baseline data for future purposes. To assess the area of pain. To assess the severity of pain. Observation may not be congruent with verbal reports. To note clients feelings towards pain. To prevent fatigue. To promote non pharmacological pain management. To promote blood circulation. For legal purposes.

Evaluation
Date: 01 07 13 Time: 4:00 pm Goal not met patient reported Sakit gihapon. PS: 4/10.

Scientific Data: Fracture incomplete or complete disruption in the continuity of bone PERCEPTUAL structure and caused by a direct blow, crushing PATTERN force, sudden twisting motion. Resulting tissue edema, hemorrhage into muscles or joints. Clininal Manisfestation: Acute Pain, deformity, loss of function, shortening of the extremity, localized edema.

COGNITIVE

Within 8 hours span of care, Monitor pt. vital patient will be able signs. to report pain is relieved/controlled Note location of from PS: 4/10 to pain. 2/10. Use pain rating scale appropriate to age. Observe non verbal cues and pain behaviors. Encourage verbalization of feelings. Encourage adequate rest. Provide comfort measures.

Elevate left lower extremities with pillows. Document all data on patients chart. Dependent: Administer meds.