no Goals Intervention Rationale

Nursing diagnosis

1 1 acute pain After the nursing 1. Examine the 1.To determine

associated with care plan given for 3 location and the right pain
joints shift x24 hours expected scale of the pain in the right
marked by bone the result are : 2. Observation vital location
and and tissue signs of the 2. To know the
trauma 1 pain can be patient patient
characterized by : reduced 3. Teach patient progress
S : patient 2 patient look calm relaxation and 3. to divert the
complaint the and more relaxed distraction patient
pain techniques attention , so
O : patients face 4. Collaborate with that patient are
look grimace
the doctor to not focus on his
give the patient pain
analgetic 4. to reduce the
medicine patients pain
Dx 2

no Nursing diagnosis Goals intervention Rationale

2. physical After the nursing care - Examine the -to

immobility related give in during 3x24 hour patients ability identification
to the pain of expected that: and functionally the main
friction joints - Patient can state on the problem
characterized by returns to damage area disturbance of
stiffness in the normal mobility - Monitoring the physical
joints . characterized - Patien can motoric function mobilitation
by : mantain his and sensory - identification
S: patint complain joint movement function the disturbance
that he can not do to the maximal everyday of physical
the activity and hard - Muscle - Do the passive mobilitation
to move strength ROM exercisess and the patient
O:patient look weak become - Change the progress
and his activity daily maximal patient potition -to determine
living assisted by his - Skin integrity after two hours
the patient
family become intact - Observation the
ability to do the
skin condition
mobilitation
- Give the skin
-prevent the
tretment
occurence of
carefully like
contractures
massage and
give oil
-the continuing
moisturizer and pressuress can
change linen or causes
patient clothing decubitus
if the linen or -to preventing
clothes are wet the decubitus
- Collaborate earlier
patient’s activity -to increase
to the circulation and
physiotherapist clasticity of
patient’s skin
and decrease
the possibility
of decubitus
-to collaborate
the patient’s
activity to the
therapist