Nursing

Diagnosis

Scientific
Analysis

Objective

Nursing
Intervention

Rationale

Evaluation

Acute pain
related to
surgery
incision on
left ankle

Acute pain is described as

an unpleasant sensory or
emotional experience
associated with actual or
potential tissue damage or
Subjective:
injury as lasting from
Sakit ang ge- seconds to 6 months. In
operahan nga cases of fracture, pain is
left ankle
continuous and increasing
nako, as
in severity until bone
verbalized by fragments are immobilized.
the patient.
In this type of fracture, the
main medical management
Objective:
is open reduction with
Incision on
internal fixation (ORIF),
the left ankle wherein the fracture
(D/3 radius L fragments are reduced and
with bone
internal fixation devices
grafting)
are used to hold the bone
fragment in position until
Posterior
solid bone healing occurs.
casts and
bandage on
left ankle
BP = 90 / 60
mmHg

After 8 hours
of nursing
intervention,
the patient:

Vital signs were

monitored q 4 hours
until stable and
dressing was
checked.

-verbalizes
minimized or Adjusted constricting
controlled
bandage and advised
feeling of pain to elevate left leg
Verbalizes
methods that
provide relief
Demonstrate
use of
relaxation
skills and
diversional
activities

Alterations from normal

may be signs of infection.
Moistened dressings are
favorable site for
microorganism to culture.
This is to prevent
diminished circulatory
and nerve function and
control swelling of the
site.

Instructed to do
activities such as
deep breathing
exercise, coughing
exercise and sitting
exercises.

To reduce swelling and

prevent stiffness the
stated activities must be
done. Decreased lung
capacity and decreased
cough efficiency are
predisposing factors to
respiratory infections.

Noted to avoid
weight bearing until
allowed.

To prevent from
complications on the
incision site, activities
that may extend the cut
must be avoided.

Encouraged to void
freely.

This is advised in order to

prevent constipation and
fecal impaction.

Enough rest and sleep This promotes healing by

was also advised.
reducing basal metabolic

Pain is reduced /
controlled to a
tolerable extent as
verbalized.
Relieving
methods and
relaxation
techniques are
understood and
demonstrated.

rate and allowing oxygen

and nutrients to be
utilized for tissue growth,
healing and regeneration.
Intake of pain
reliever and
antibacterial
medications as per
doctors order and
advise.

NSAID activity includes

modulation of T-cell
function, inhibition of
inflammatory cell
chemotaxis, decreased
release of superoxide
radicals, or increased
scavenging of these
compounds at
inflammatory sites.
Antibiotics are used to
treat and prevent
infections caused by
susceptible pathogens.