GLOBAL CITY INNOVATIVE COLLEGE

Transforming Lives. Innovative Education .

Name: Ilona Rosabel Bitalac Patient’s Name: D.T. Age: 36 years old Diagnosis: skin grafting forearm right fracture, open III-B, comminuted , proximal middle 3rd, radius – ulna right secondary to GSI; s/p application of external fixator, radius, right s/p debridement, forearm, right. Assessment Nursing Analysis Planning Implementation Rationale for Evaluation Diagnosis Goal and Nursing Objective Intervention Risk for Trauma on skin After 2 hours of Independent: After 2 hours of Subjective: “meron akong infection related at the left thumb nursing nursing sugat sa kaliwa to inadequate intervention, the >Monitor V/S >to note increase intervention the kong kamay” as primary defense patient will be especially in temperature. goal was met as verbalized by the as manifested by Broken skin able to gain Temperature. evidenced by the patient. broken skin. knowledge in patient has able infection control >Establish >to gain trust to gained Open wound as evidenced by rapport. and cooperation knowledge in Objective: T- 36.5 discussing the with the patient. infection control P- 80bpm proper wound as evidenced by R- 20 cpm Risk for care. >Teach patient >to reduce the his discussion in BP120/80mmHg infection to wash hands risk for proper wound often, especially infection. care. -Open wound after toileting, with external before and after fixator. administering self care. >discuss to patient the following signs of infection: >to impart to the patient when the wound become infected and

GLOBAL CITY INNOVATIVE COLLEGE
Transforming Lives. Innovative Education .

Redness, swelling, increase pain, drainage on the site and fever. >Maintain aseptic technique when changing dressing care wound.

when to sought medical care.

>regular wound dressing promotes fast healing and drying of wounds. >wet area can be lodge area of bacteria. >to know if the patient really understand the principle of proper wound care. >to inform the patient the risk for discontinuation of treatment.

>Keep area around wound clean and dry. >Demonstrate and allow return demonstration of wound care.

>emphasize necessity of taking antibiotics as directed. Dependent:

GLOBAL CITY INNOVATIVE COLLEGE
Transforming Lives. Innovative Education .

Administer medication as ordered: >Tramadol 500mg 1 tab. prn. Collaborative: x-ray

>for pain management as necessary.

>to reveal bone structure was immediately recognized as a medical diagnostic tool.

GLOBAL CITY INNOVATIVE COLLEGE
Transforming Lives. Innovative Education .

Name: Ilona Rosabel Bitalac Patient’s Name: B. R. A. Age: 23 years old Diagnosis: s/p completion amputation 4th & 5th rays hand (L) (open stamp) Fx open comminuted d/3 clavicle secondary to GSI. Assessment Nursing Diagnosis Planning Goal and Objective
After 2 hours of nursing intervention, the patient will be able to decrease level of pain with a pain scale of 3/10.

Implementation

Rationale for Nursing Intervention > to provide baseline data.
>to obtain baseline data.

Evaluation

Subjective:
“Sumasakit ang kaliwa kong braso” as verbalized by the patient. Acute pain related to underlying physical agents of the bone as evidenced by comminuted clavicle secondary to gun shot injury.

Independent:
>Monitor V/S

Objective: T- 36.5 P- 75bpm R- 20 cpm BP130/90mmHg - Observed
evidence of pain - Guarding behavior -Expressive behavior (Restlessness) -facial grimace -Pain scale of 7/10

>Assess the condition of the patient. >Determine and document presence of possible pathophysiological / psychological causes of pain (e.g. inflammation, infections, etc). >Observe nonverbal cues behaviors (e.g. how client walks,

>to lessen and avoid the pain by proper management.

After 2 hours of nursing intervention, goal was met; as evidenced by patient pain was decreased with a pain scale of 3/10.

>to anticipate pain and provide proper care.

GLOBAL CITY INNOVATIVE COLLEGE
Transforming Lives. Innovative Education .

sits, etc). >Ascertain client’s knowledge of and >to be able to expectations about respond to pain management. therapeutic management >Determine client’s acceptable >to be able to level of pain. establish patient’s trust in you and not to give further pain to the patient.

>Provide comfort measures such as touch, repositioning, etc. >Encourage use of relaxation techniques such as deep breathing exercise. >refer to physician

>to lessen the pain.

>to divert attention of pain.

Dependent: Administer medication as ordered:

>to provide further care.

GLOBAL CITY INNOVATIVE COLLEGE
Transforming Lives. Innovative Education .

>tramadol 500 mg 1 tab. prn Collaborative: x-ray

>for pain management.

>to reveal bone structure was immediately recognized as a medical diagnostic tool.