CUES NURSING SCIENTIFIC GOAL & NURSING RATIONALE EVALUATION

DIAGNOSIS BASIS OUTCOME ACTIONS &

CRITERIA NURSING
ORDERS

a
Subjective cues: Impaired Fractures occur After 8 hours of After 8 hours of

vi
-“ sakit akong luyo ug physical when the bone is rendering appropriate rendering
wala nga tiil” as mobility, subjected to stress nursing interventions appropriate
verbalized by the patient. inability to stand greater that it can the patient will be nursing

d
alone related to absorb. When the able to: interventions the

e
Objective cues: skeletal bone is broken, patient was able:

ar
-received patient lying impairment to adjacent structures 1. Demonstrate Independent -to improve
on bed, awake, coherent, facture of the left are also affected, increasing - assist patient to muscle 1.Demonstrate

sh
& responsive. femoral neck resulting in soft function of do active ROM strength and increasing function
tissue edema, the exercises on the joint mobility. of the extremities.
-IVF of 1 L # 21 PLR hemorrhage into extremities. (GULANICK

as
lower extremities.
with remaining 270 mL the muscles and & MYERS: 2.Regain or
@ 30 gtts/min. infusing joints, joints 2007, p. 127) maintain mobility

w
well @ right arm. dislocations, at the highest
ruptured ten-dons, -in order for possible level.

m e
- grimace face noted severed nerves, Dependent the muscle to

- limited ROM co rc
and damaged blood
vessels. Body
-administer
analgesics such as
be more relax
and relieves
3. Verbalize
understanding of
o. ou
organs maybe Tramadol (Tramal) the pain the situation /risk
injured by the as prescribed by (GULANICK factors, individual
er res
force that caused the physician. & MYERS: therapeutic
-v/s the fracture 2007, p. 127) regimen and
 BP: 130/80 fragments. After a safety.
mmHg fracture, the -to develop
se dy

 T : 38.2°C extremities cannot individual -Goal was met

Collaborative
 P : 75 bpm function properly exercise or
- consult with
ur tu

 R : 20 cpm because normal mobility

functions of physical or program and
s
H

muscle depend on occupational identify

the integrity of the appropriate
is

therapist as
bones which they adjunctive
Th

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 are attached. indicated. devices.
(Gulanick & (GULANICK
Myers: 2007, p. & MYERS:
126) 2007, p. 129)
2. Regain or
maintain -patient may
mobility at be restricted

a
the highest by self-view

vi
possible or self-
level. Independent perception out
of proportion

d
-assess degree of
with actual

e
mobility produced
physical

ar
by injury or limitations
treatment and note requiring

sh
patient’s interventions
perception of to promote
progress

as
immobility.
toward
wellness.

w
(GULANICK
& MYERS:

m e
3. Verbalize 2007, p. 127)

co rc understanding
of the
o. ou
situation /risk
factors,
er res
individual
therapeutic
regimen and
safety
se dy

measures.
ur tus
H
is
Th

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 NURSING SCIENTIFIC BASIS GOAL & NURSING
CUES DIAGNOSIS OUTCOME ACTIONS & RATIONALE EVALUATION
CRITERIA NURSING
ORDERS
Subjective cues: Alteration in Pain is a typical sensory After 8 hours of After 8 hours of
-“ sakit akong luyo ug comfort : Acute experience that may be rendering rendering

a
wala nga tiil” as Pain related to described as the appropriate appropriate nursing

vi
verbalized by the tissue trauma 2° unpleasant awareness of nursing intervention, the
patient. to MVA a noxious stimulus or intervention, the patient was able to
bodily harm. patient will be have reduction of

d
Objective cues: Individuals experience able to reduced pain from 8 to 4 with

e
-received patient lying pain by various daily pain from 8 to 4 10 as the most

ar
on bed, awake, hurts and aches, and with 10 as the painful.
coherent, & responsive. occasionally through most painful. Independent

sh
more serious injuries or - perform proper - appropriate 1. The patient will
- diaphoresis illnesses. Pain is 1. The patient nursing verbalize
measures will
defined scientifically as will verbalize reduction of pain

as
interventions be
- pain scale of 8/10, as unpleasant sensory and reduction of and appropriate from a pain scale
of 0 is no pian and 10 emotional experience pain from a implemented of 4 in a 0-10

w
procedures to
is the most painful associated with actual pain scale of alleviate pain. to prevent scale with 10 as
or potential tissue 4 in a 0-10 infections and the most painful.

m e
-guarding behavior damage, or described in scale with 10 complications. 2. Patient will

- T : 38.2°C co rc
terms of such damage.
Pain of any type is the
as the most
painful.
-use non-
pharmacologic - use of non- demonstrate
ways to reduce
o. ou
interventions for pharmacologic
most frequent reason methods will pain.
relieving pain
why people tend to seek embrace the
(eg. Relaxation)
er res
medical consultation. It results of pain 3. The patient will
is a major symptom in reliever. Gate appreciate the
O – occurs many medical control theory care rendered.
when moving conditions, significantly
se dy

states that
L – on his left leg interfering with a cutaneous - Goal was met
D – approximately 1 person’s quality of life stimulation
ur tu

min. and general functioning. closes the pain

C – gnawing pain Diagnosis is based on pathways.
s
H

A – frequent characterizing pain in (BARE &

is

moving various ways, according SMELTZER,

R – rest to duration, intensity,
Th

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T – Tramadol (Tramal) type (dull, burning or 2004: 1140)
stabbing), source, or Dependent
location in body. --administer -in order for
Usually, pain stops analgesics such the muscle to
without treatment or as Tramadol be more relax
responds to simple (Tramal) as
measures such as and relieves
prescribed by the

a
resting or taking an the pain
physician.

vi
analgesic, and it is then (GULANICK
called acute pain. But it & MYERS:
may become intractable 2007, p. 127)

d
and develop into a

e
condition called chronic

ar
pain, in which pain is Independent
no longer considered a - instruct patient

sh
symptom but an illness to use relaxation -diverts
by itself. The study of exercises such as attention and
pain has it recent years focused may enhance

as
2. Patient will
attracted many different breathing, coping
demonstrate
fields such as commercial or abilities.

w
ways to
pharmacology, individualized (DOENGES,
reduce pain.
neurobiology, nursing tapes. 2002:368)

m e
sciences, dentistry,

co rc
physiotherapy, and
psychology. Pain
Dependent
-provide
o. ou
medicine is a separate individualized -promotes
subspecialty figuring physical therapy active, not
er res
under some medical or exercise passive role.
specialties like program that can (DOENGES,
anesthesiology, be continued by 2002: 369)
physiatry, neurology, the client when
se dy

and psychiatry. Pain is discharged.

part of the body’s
ur tu

defense system, Collaborative

triggering a reflex -encourage
s
H

reaction to retract from patient to have -bed rests

a painful stimulus, and adequate bed decreases body
is

helps adjust behavior to rest periods. metabolism

Th

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 increase avoidance of and thus
that particular harmful reduces muscle
stimulation in the tension.
future. Given its (BARE &
significance, physical SMELTZER,
pain is also linked to 2004: 1140)
various cultural,

a
religious, philosophical, Independent - Establish a

vi
or social issues. -establish a trusting
(http://en.wikipedia.org) specific time to relationship
talk with patient that

d
about pain and encompasses

e
its psychological patient’s

ar
and emotional physiological,
effects. emotional,

sh
social, sexual,
3. The patient and financial

as
will concerns.
appreciate the (SPARKS &

w
care TAYLOR,
2005: 227)
rendered.

m e
- Pain is a
co rc Dependent
subjective
experience and
o. ou
-accept client’s cannot be felt
description of by others.
er res

pain. (DOENGES,
2002: 367)
se dy

- to achieve
pain
management
ur tu

Collaborative goals and

-work closely maximize
s
H

with staff and patient’s

is

patient’s family. cooperation.

Th

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 (SPARKS &
TAYLOR, 2005:
227)

NURSING SCIENTIFIC BASIS GOAL & NURSING

a
CUES DIAGNOSIS OUTCOME ACTIONS & RATIONALE EVALUATION

vi
CRITERIA NURSING
ORDERS
Subjective

d
cues:

e
-“lisod man

ar
ilihok akong
lawas” as

sh
verbalized by
the patient.

as
w
m e
co rc
o. ou
er res
se dy
ur tus
H
is
Th

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