Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: “Masakit yung kaliwang panga ko.” as verbalized by patient. Objective: Facial mask of pain. Guarding, protective behavior. V/S taken as follows: T: 37 C P: 66 bpm R: 14 cpm Bp: 110/70 mmhg Pain scale of 8/10

Acute pain related to condylar neck fracture of the mandible (close) as manifested by inflammation on the site of injury

After 8 hours of nursing interventions, the patient will express feeling of comfort and relief of pain.

Independent: Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (scale of 0-10), relieving and aggravating factors. Note non-verbal pain cues such as changes in v/s and emotions or behavior. Listen to reports of family member/significant other regarding client’s pain Encourage client to discuss problems related to injury Influences choice of, ad monitors effectiveness of interventions. Many factors including level of anxiety may affect perception of and reaction to pain. Note: Absence of pain expression does not necessarily mean lack of pain.

After 8 hours of nursing interventions, the patient had expressed feeling of comfort and relief of pain

Helps alleviate anxiety. Client may feel need to relieve the accident experience. Allows client to prepare mentally for activity and to participate in controlling discomfort

Explain procedures before beginning them

Apply cold compress on the site of injury

To relieve pain and reduce inflammation

Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities such as listening to music, watching TV, etc.

Promotes relaxation and may enhance patient’s coping abilities by refocusing attention. Diversional activities aids in refocusing attention and enhancing coping with limitations.

Collaborative: Administer analgesics as prescribed by the physician To maintain acceptable level of pain.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: “Lumalabo yung paningin ko sa kanang mata.” as verbalized by patient. Objective: Closing right eye to see Blurred, double vision (Diplopia) Anxiety Change in usual response to visual stimuli History of accidents (vehicular) · V/S taken as follows: T: 37 C P: 80 bpm R: 14 cpm Bp: 100/80 mmhg

Disturbed Sensory Perception: Visual related to orbital zygomaticomaxillary complex fracture as manifested by blurred, double vision (Diplopia)

After 8 hours of nursing interventions, the patient will achieve optimal functioning within limits of visual impairment as evidenced by ability to care for self, to navigate environment safely, and to engage in meaningful activities.

Independent: Introduce self to patient, and acknowledge visual impairment Provide adequate lighting This reduces patient’s anxiety

The use of natural lighting is preferred to improve vision for patients with diminished vision These ensure safety and sense of independence

After 8 hours of nursing interventions, the patient achieves optimal functioning within limits of visual impairment as evidenced by ability to care for self, to navigate environment safely, and to engage in meaningful activities.

Place meal tray, tissues, water, and call light within patient’s range of vision or reach Communicate type and degree of impairment to all involved in patient’s care Encourage use of sense of touch

This enhances continuity of care

Touch encourages patient to become familiar with unfamiliar objects

Remove environmental barriers to ensure safety.

This ensures safety. If furniture or wastebaskets are moved, notify patient of changes Side rails help remind patient not to get up without help when needed

Maintain bed in low position with side rails up, if appropriate

Demonstrate the proper administration of eye drops or ointments; allow for return demonstration by patient and/or caregiver.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: “May sugat ako sa paa at makati din ito.” as verbalized by patient. Objective: Multiple hyperpigmented papule Scaling and flaking of the affected skin Presence of blisters and cracked skin (+) Swelling and inflammation V/S taken as follows: T: 37 C P: 78 bpm R: 14 cpm Bp: 120/80 mmhg

Impaired skin integrity related to tine pedis as manifested by multiple hyperpigmented papule

Following 3-day nursing interventions, the patient will be able to display improvement of wound healing and relieve of itchiness.

Independent: Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes. Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully. Establishes comparative baseline providing opportunity for timely intervention. Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. Improved nutrition and hydration will improve skin condition.

Following 3-day nursing interventions, the patient had displayed improvement in wound healing and relief of itchiness.

Instructed family to maintain clean, dry clothes, preferably cotton fabric (any Tshirt).

Emphasized importance of adequate nutrition and fluid intake.

Instructed family to clip and file nails regularly.

Long and rough nails increase risk of skin damage.

Instruct the patient regarding the treatment regimen ordered by the physician (SSA Soap, KMn04 solution)

NURSING CARE PLAN

Suarez, Suzaine Marie F. BSN 3Y3-8E

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