Nursing Diagnosis: Acute and chronic pain related to fracture,soft tissue

damage,muscle spasm and surgery.

Goal:Relief of pain.

Planning:

1)Monitor and documention of vital signs.

2)Asses pain level.

3)Asses presence of edema.

4)Positioning for comfort and function.

5)Administer prescribed medication.

Nursing Intervention:

1)Monitor and document vital sign such as blood pressure,tenperature,respiratory,

Pulse rate to detect any abnormalities to provide treatment and medication

according patient condition.

2)Asses type and location of patient’s pain whenever vital signs are obtained and as

Needed.Pain is expected after fracture,soft tissue damage and muscle spasm

Contribute discomfort,pain is subjective and is best evaluatedon a pale scale of

0 to 10 and through description of characteritics and location,which are important

For identifying cause of discomfort and for proposing interventions.

3)Assess edema and provide cold and heat application to reduce pain.Cold reduces

Pain,inflammation and muscle spasticity by decreasing the release of pain-

Inducing chemicals and slowing the conduction of pain impulses.Heat reduces

Pain through improved blood flow to the area and through reduction of reflexes.

Special attention need to be given to preventing burns with this intervention.

4)Alignment of body ficilitates comfort,positioning for function diminishes stress

Muscuoskeleta system.Change of position relieves preesure and asscociated

Discomfort.

5) Encourage patient to use pain medication such as nonnarcotic analgesic

 (examples are:acetylsalicyclic acid (aspirin) and acetaminophen(Tylenol)),narcotics
(examples are:meperidine (Domerol) and Morphine and codeine) to relieve pain.

Nursing Diagnosis:Imbalanced nutrition less than body requirement related to

nausea,vomiting evidance by less of body weight.

Goal:Remaine nutrition intake

Planning

1.Monitor patient weight daily.

2.Determine etiologi factors reduced nutritional intake.

3. Encourage patient to consult dietition

4.Suggest ways to assist patient,with meals as needed.

5.For hospitalized patient,encourage family to bring food from home as appropriate.

Nursing Intervention

1.Monitor weight daily,consistenly with same scale at the same times of the day to
monitor the weight chance.

2.Detemine factor for reduced nutritional intake to provide treatmen and medication
to overcome patient main probleum like vomiting and nausea.For example
administer (ORS) oral rydration salt medication to reduce vomiting.

3.Consult dietition for futher assessment and nutritional support.Dietition have a

greater understand of food and many be helpful in assessing specific ethnic or
cultural food.

4.Suggest ways to assist patient with meals as needed.Ensure a pleasent

environment,facility,proper position and provide good hygiene .

5.For hospitalized patient,encourage family to bring food from home as

appropriate.Because patient with specific ethnic,religious preferences and
restrictions may not be able to eat hospital food.

Evalution

Maintained patient body weight

Nursing Diagnosis:Activity intolerance related to fatigue and surgery.

Aim:Absence to activity intolerance

Planning

1.Encourage patient to rest after surgery.

2.Encaurage alternating activity with rest.

3.Assist patient to plan activites for time when she/he has most energy.

4.Monitor the patient nutritional intake.

5.Minimize environmental stimuli,expecialy during planned time for rest and sleep.

Nursing Intervention

1.Encourage patient to rest after surgery to consume energy.

2.Encourage adequet rest period expecialy before take meal,exercise session and
ambulation.Rest between activity for energy conservation and recovery.

3.Assist patient to plan activity,when he/she has most energy.Such as encourage

active foot exercises,walking and others.

4.Monitor patient nutritional intake for adequate energy sources and metabolic
requirements.The patient will need adequate intake of carbohydrates,
calcium,magnesium,fosforat ,minerals and vitamin to provide energy resources to
avoid fatigue.

5.Minimize environmental stimuli,expecialy during planned times for sleep to take

adequate rest with not any disturbend.

Evalution:Patient can participan in daily activity within tolerance.

Nursing diagnosis:Risk for infection related to surgical incision.

Goal:Maintains asepsis

Planning

1.Monitor vital signs

2.Perform asepsis dressing changes

3.Assess wound appearance

4.Assess report of pain

5.Administer prophylactic aneibiotik if prescribed and observe for side effects.

Intervention

1.Monitor vital signs because temperature,pulse and respiration increase in

response to infection.

2.Perform asepsis dressing changes to avoid infection.

3.Red,swollen,draining incision is indicative of indicative of infection.Special

therapeutic beds or mattress may be needed to prevent skin breakdown and to
promote wound healing after extensive surgical reconstruction.

4.Pain may due to wound,inflammation,swelling,and minimizes pressureon the

wound site to promote circulation.

5.Antibiotics help to reduce the risk for infection.

.Evalution:To reduce transmission of microorganism to patient.