Subjective Objective Analysis Diagnosis Planning Intervention Evaluation

“Sumasakit ang -Incision on the Acute pain is Pain r/t surgical After 1-2 1)Monitor VS After 1-2
inoperahan sa left forearm described as an incision as hours of R=abnormal hours of
akin” as with plates and unpleasant manifested by: rendering ranges may rendering
verbalized by the screws. sensory or nursing indicate nursing
patient emotional -Incision on the interventions infection. interventions
-Swelling on left experience left forearm the patient’s the patient’s
arm. associated with with plates and pain scale will 2)Elevate L arm pain scale
actual or screws. be lessen R=to reduce was lessen
-Slowed potential tissue from 8/10 to swelling of the from 8/10 to
movement. damage. In -Swelling on left at least 3/10. site. 2/10.
this type of arm.
-Pain scale of fracture, the 3)Perform a Goal is met
8/10. main medical -Slowed comprehensive
management is movement. assessment of
ORIF (open pain
reduction -Pain scale of R=pain is a
internal fixation) 8/10. subjective
wherein experience and
the fracture must be
fragments are described by
reduced and the client in
internal order to plan
fixation effective
devices are treatment.
used to hold
the bone 4)Encourage to
fragment in rest
position until R=promotes
solid bone healing.
healing occurs.
5)Advised to
void freely
R=to prevent
fecal
impaction.

6)Analgesics as
prescribed
R=to relieve
the pain.
 Subjective Objective Analysis Diagnosis Planning Intervention Evaluation
“Hindi ko -Tired facial ORIF (open Activity After 3 hours 1)Establish After 3 hours
magawa ang mga expression. reduction intolerance r/t of rendering rapport of rendering
bagay na gusto internal fixation) physical agent nursing R=to gain trust nursing
kong gawin dahil -Worried. is a method of as manifested interventions and interventions
sa opera ko” as surgically by: the patient cooperation. the patient
verbalized by the -Uncomfortable. repairing of a will report was able to
patient fractured bone. -Tired facial activity 2)Monitor VS report
-With limited Wherein the expression. intolerance R=to obtain activity
range of fracture with baseline data. intolerance
motion. fragments are -Worried. enhanced with
reduced and energy. 3)Provide enhanced
-Incision on left internal -Uncomfortable. enough energy.
arm with plates fixation ventilation
and screws. devices are -With limited R=to enhance Goal is met
used to hold range of patient’s ability
the bone motion. to cooperate.
fragment in
position until -Incision on left 4)Promote
solid bone arm with plates safety
healing occurs. and screws. measures
R=to prevent
injury.

5)Provide
health
teachings
R=to provide
adequate
knowledge.

6) Encourage
to rest
R=promotes
healing.