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