Assessment Diagnosis Scientific rationale Planning Implementation Scientific rationale Evaluation

Subjective: Acute pain related Acute pain is After 8 hours of nursing  Vital signs were  Alterations After 8 hours of
to Open Reduction described as an intervention, the patient monitored q 4 from normal nursing intervention
Internal Fixation unpleasant sensory will: hours until stable may be signs the pain is reduced
(ORIF) on left or emotional and dressing was of infection. controlled to a
femur experience a) Verbalizes checked. Moistened tolerable extent as
associated with minimized or dressings are verbalized.
actual or potential controlled favorable site Relieving methods
Objective: tissue damage or feeling of pain for and relaxation
injury as lasting microorganism techniques are
V/S as Follows: from seconds to 6 b) Verbalizes to culture. understood and
BP : 120/80 months. In cases of methods that  Adjusted  This is to demonstrated.
mmHg fracture, pain is provide relief constricting prevent
PR : 72 bpm continuous and bandage and diminished
RR : 24 cpm increasing in c) Demonstrate use advised to elevate circulatory and
Temp. : 36.8 C severity until bone of relaxation Right leg nerve function
fragments are skills and and control
immobilized. In this diversional swelling of the
type of fracture, the activities site.
main medical  Instructed to do  To reduce
management is open activities such as swelling and
reduction with deep breathing prevent
internal fixation exercise, coughing stiffness the
(ORIF), wherein the exercise and sitting stated
fracture fragments exercises. activities must
are reduced and be done.
internal fixation Decreased
devices are used to lung capacity
hold the bone and decreased
fragment in position cough
until solid bone efficiency are
healing occurs. predisposing
factors to
respiratory
infections.
 Noted to avoid  To prevent
weight bearing from
until allowed. complications

17 | P a g e
 on the incision
site, activities
that may
extend the cut
must be
avoided.
 Encouraged to  This is advised
void freely. in order to
prevent
constipation
and fecal
impaction.
 Enough rest and  This promotes
sleep was also healing by
advised. reducing basal
metabolic rate
and allowing
oxygen and
nutrients to be
utilized for
tissue growth,
healing and
regeneration.
 Intake of pain  NSAID is an
reliever and example to
antibacterial relieve severe
to moderate
pain

Assessment Diagnosis Scientific Planning Implementation Scientific rationale Evaluation

18 | P a g e
 rationale
Subjective: Impaired physical Open reduction At the end 6hours of  Determine  To identify After 6hrs. of nurse-
“Hindi ko maigalaw mobility related to internal fixation nurse-patient diagnosis that contributing patient interaction and
ung binti ko ”, as Open Reduction is a method of interaction and contributes to factors intervention, the patient
verbalized by the Internal Fixation surgically intervention, the immobility. has:
patient repairing a patient will:  Note situations  Because it may
fractured bone. such as fractures restrict a.) Verbalized
Generally, this a.)Verbalize movement understanding
involves either understanding of the  Determine the  To assess of the situation
the use of plates situation and degree of functional and individual
and screws or an individual treatment immobility in mobility treatment
Objective: intramedullary regimen and safety relation to regimen and
 limited range (IM) rod to measures. suggested scale safety
of motion stabilize the  Determine  To assess measures.
 slowed bone. And due to b.)Participate in presence of presence of b.) Participated in
movement the ORIF the ADLs and desired complications complications ADLs and
 limited ability patient is activities related to desired
to perform restricted to immobility(pneum activities
gross and fine move. c.) Maintain position onia, elimination c.) Maintained
motor of function and skin problems, position of
 with ORIF on integrity as decubitus) function and
Right leg evidenced by  Assist client  to promote skin integrity as
absence of decubitus reposition self on a optimum level of evidenced by
V/S as Follows: ulcers regular schedule function and absence of
BP : 120/80 prevent decubitus
mmHg d.) Maintain and complication ulcers
PR : 72 bpm increase strength and  To maintain d.) Maintained and
RR : 24 cpm function of affected  Support affected position and increased
Temp. : 36.8 C part. body part using function and strength and
pillows. reduce risk of function of
pressure ulcers. affected part.

 It promote well-
 Encourage being and
adequate intake of maximizes
fluids/nutritious energy
foods production
Assessment Diagnosis Scientific Planning Implementation Scientific rationale Evaluation

19 | P a g e
 rationale
Subjective: Risk for infection Trauma After 6 hours nurse-  Note risk factor for  To assess After 6hr nurse-patient
“” as verbalized by the related to wound (Vehicular patient interaction occurrence of causative/contrib interaction and
patient secondary to accident) and intervention the infection uting factors intervention the patient
fracture patient will:  Observe for  To assess for has:
Fracture of the localized signs of infected sites
left leg a) Identify infection. a) Identified
interventions  Stress proper hand-  A first line interventions to
Bleeding from to hygiene by all defense against prevent/reduce
Objective: damaged ends of prevent/redu caregivers bet. healthcare- risk of infection
bone and ce risk of Therapies/clients associated
 Open wound surrounding infection infection b) Achieved
tissue  Recommend  To reduce timely wound
 ORIF on left b) Achieve routine or body bacterial healing; be free
Femur Broken timely shower/scrub when colonization of purulent
skin(wound) wound indicated drainage or
 Immobility healing; be  Change surgical or  To prevent erythema;
Risk for infection free of other wound infection
V/S as Follows: purulent dressings, as c) Been afebrile as
BP : 120/80 drainage or indicated, using evidenced by
mmHg erythema; proper technique the normal V/S
PR : 72 bpm for changing or
RR : 24 cpm c) Be afebrile disposing of
Temp. : 36.8 C as evidenced contaminated
by the materials
normal V/S  Review individual  To promote
nutritional needs, wellness.

20 | P a g e