Patient name: PFC G., F. L.

Diagnosis: Non-Union, proximal Femor with RMFB L , S/P ROI (DCHS) Prox Femur L (2010) S/P PHA L (2010)

NURSING CARE PLAN

CUES
Subjective Objective *facial grimace *restlessness *skin pale and moist *guarding/ self-focus *pain scale: 5/10 *BP: 130/80bpm Temp: 36.7C RR: 15 bpm PR: 75 bpm

NURSING DIAGNOSIS
Acute pain related to post-op surgery and muscle spasms

RATIONALE
Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury as lasting from seconds from 6 months. In cases of fractures, pain in continuous and increasing in severity until bone fragments are immobilized.

GOAL
After 6 hours of nursing intervention, the patient will: -Verbalizes minimized or controlled feeling of pain; pain scale from 5/10 to 3/10 -Verbalized method that provides relief. -Demonstrates use of relaxation skills and diversional activities

NURSING INTERVENTION
Independent: -Vital signs were monitored and recorded until stable and dressing was done. -Assessed level of consciousness (LOC) and turned every 2 hours, to inoperative side only. -Instructed to do activities such as deep breathing exercise, coughing exercise and dorxiflexion of foot.

RATIONALE OF THE NURSING INTERVENTION Alterations from normal may be signs of infection. Moistened dressing is favorable site for microorganism to culture. -One must be conscious and awake in order to feel pain. Turning of position prevent bed sores. -to reduce swelling and prevent stiffness the stated activities must be done. Decreased lung capacity and decreased cough efficiency are predisposing factors to respiratory infection. -Helps alleviate anxiety. Patient may feel need to relive the accident experience. -Improves general

EVALUATION
After 6 hours of intervention some of the desired outcome has been met. Such as, the client participated in the prevention and treatment program by verbalizing controlled feeling of pain with the scale pain of 4/10, understanding the methods that provide relief, demonstrating self care activities.

May nararamda man akong kirot sa aking opera sa tuwing kikilos ako sa aking kama As verbalized by the patient.

-Encouraged patient to discuss problems related to injury. -Provide alternate comfort

as indicated for her situation.

measures, e.g., massage, back rub, position changes. -Enough rest and sleep was also advised.

circulation; reduces areas of local pressure and muscle fatigue. -this promotes healing by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration. -Many signal developing complication.

-Investigated any reports of unusual/sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics.