You are on page 1of 6

NAME: MAESTRADO, AIVEN CLAIRE A DATE: JUNE 20.

2009
C.I: JOJEBELLE KATE I. CABANLET NURSING CARE PLAN SHIFT: 7-3

CUES AND NURSING GOAL OF CARE NURSING INTERVENTION RATIONALE EVALUATION


EVIDENCES DIAGNOSIS

SUBJECTIVE: Acute pain related to At the end of DIAGNOSTIC


“sakit akong left distal radial my8hrs. duty, my → Monitored V/S To establish baseline data
kamot kung fracture and left & client will be able → Followed up wrist xray result Confirmation of fractures At the end of my 8hrs duty,
lihokon og right distal radial and to: the goal of care was fully met
tandogon” as ulnar fracture. THERAPEUTIC as the pt. verbalizes relief of
verbalized by → verbalizes → Administered medication To maintain acceptable pain and demonstrated use of
the pt. method to provide such as analgesic( mefenamic) level of pain. diversional activities and
relief → Provided comfort measures To provide relaxation technique.
OBJECTIVES: such as repositioning every 2hrs. nonpharmacological pain
Facial grimace →verbalize relief management
Diaphoresis of pain EDUCATIVE
Restlessness → Encouraged diversionaL Divert feeling of pain
crying →demonstrate use activities such as talking to the
of diversional SO.
activitiey and → Instructed to use relaxation Provides opportunity to
relaxation technique such as focused refocus his attention
technique. breathing.
→ Encouraged verbalization of May felt need to relieve
feelings about pain. accident experience
→ Encouraged to immobilized Prevents further bone
the affected area injury
→ Encouraged to have adequate Prevent fatigue.
rest.
SUBJECTIVE: At the end of my DIAGNOSTIC At the end of my 8hrs duty,
“ dili nako Impaired physical 8hrs duty, my client → Monitored V/S To establish baseline data the goal of care was fully met
malihok-lihok mobility related to will be able to: → Assessed degree of To promote progress as the pt. demonstrated
akong kamot ky pain as evidenced by immobility produced by injury. toward wellness technique to enable
sakit siya kung left distal radial → demonstrate indicated. resumption of activities and
matandog” as fracture and left & technique that THERAPEUTIC participation in diversional
verbalized by right distal radial and enables resumption → Assisted with active/passive Increases blood flow to activities.
the pt. ulnar fracture. of activities. ROM exercises of unaffected muscles and bones to
extremities. improve muscle tone and
→ demonstrate joint mobility to promote
OBJECTIVES: participation of healing.
Limited range activities. → Instructed SO to ambulate pt. Increases blood
of motion in the circulation and return
upper physical function.
extremities EDUCATIVE
Slowed → Encouraged participation of Provides opportunity to
movement diversional activities such as refocus his attention.
focused breathing and talking to
the SO.
→ Encouraged to eat high in Provides nutrients needed
calcium and protein like meat for bone and muscle
and milk. repair and healing.
Risk for further At the end of my DIAGNOSTIC At the end of my 8hrs duty,
injury 8hrs duty, my client → Assessed muscle strength, To compare baseline the goal of care was fully met
will be able to: gross and fine motor data. as the pt. demonstrated
coordination. behaviors to reduce risk and
→ demonstrate protect self from further
behaviors to reduce THERAPEUTIC injury and to enhance safety.
risk and protect self → Assisted in a comfortable To promote rest.
from further injury. position.
→ Demonstrated use of Promote relaxation.
→ modify techniques to reduce stress.
environment as → Reduced environmental Reduces restlessness.
indicated to stimulation such as providing
enhance safety. calm environment.

EDUCATIVE
→ Instructed to have an assistant Promote safety.
when doing ADLs.
→ Instructed SO to maintain Enhance safety.
environment unobstructed during
ambulation.

You might also like