1. Carry out the doctor's order (e.g.

kardex, meds chart, tickets)


NURSING DIAGNOSIS: Acute pain r/t movement of bone fragments, edema, and injury to the soft tissue.
ASSESSMENT
SUBJECTIVE CUES:
❖ “Sakit kayo Ma’am di ko
ganahan mulihok” As
verbalized by the patient
OBJECTIVE CUES:
❖ Weakness noted
❖ Pain scale of 9/10
❖ Presence of facial grimace
❖ Discomfort was observed
❖ Vital Signs:
• Temperature: 36.9 OC
• Pulse Rate: 85 bpm
• Respiratory Rate: 18
cpm
• Blood Pressure: 100/70
mmHg
6. NCP (minimum of 3)
PLANNING INTERVENTIONS RATIONALE EVALUATION
At the end of 8 hours of student INDEPENDENT: At the end of 8 hours of student
nurse – client interaction, there nurse – client interaction, the
will be relief of pain as 1. Monitor patient’s pain using ✓ Pain assessment determines goal was:
evidenced by: COLDSPA the effectiveness of
1. Client will verbalize relief of interventions. Many factors, 1. Partially met- Patient’s level of
pain, pain scale of 1-3 out of including the level of pain reduces into 4/10.
10. anxiety, may affect the
perception of pain. 2. Partially met- Patient was
slightly relaxed
2. Client will display relaxed
manner. 2. Maintain immobilization of ✓ Immobilization relieves pain
affected part using bed rest, and prevents bone 3. Met-patient was attentive and
cast (if indicated) displacement and extension willing to participate on the
3. Client will demonstrate of tissue injury. activities and procedures that
ability to participate in should be done.
activities with minimal 3. Elevate and support injured ✓ Promotes venous return,
complaints of discomfort. extremity. decreases edema and may 5. Met-patient shows
reduce pain. demonstration of relaxation
4. Client will demonstrate use skills and diversional
of relaxation skills and 4. Elevate bed covers; keep ✓ Maintains body warmth activities as indicated for
diversional activities as linens off toes. without discomfort due to individual situation.
indicated for individual the pressure of bedclothes on
situation. affected parts.
5. Explain procedures before ✓ Allows the patient to prepare
starting them.(ORIF plating, mentally for activity and to
tibia right, closed reduction, participate in controlling the
application of cast) level of discomfort.
6. Perform and supervise active ✓ Maintains strength and
and passive ROM exercises.
7. Provide alternative comfort
measures (massage,
backrub, position changes,
deep breathing)
DEPENDENT:
8. Administer Medication as
prescribed, ketorolac
(Toradol) for bone pain.
mobility of unaffected
muscles and facilitates
resolution of inflammation in
injured tissues.
✓ Improves general
circulation; reduces areas of
local pressure and muscle
fatigue.
✓ Injectable and oral
nonsteroidal anti-
inflammatory drugs
(NSAIDs): ketorolac . Given
to reduce pain or muscle
spasms. Administer
analgesics around the clock
for 3–5 days. Studies of
ketorolac (Toradol) have
proven effective in
alleviating bone pain, with
longer action and fewer side
effects than narcotics agents.
NURSING DIAGNOSIS: Impaired Physical Mobility r/t neuromuscular skeletal impairment; discomfort; restrictive therapies as evidenced by
inability to move purposefully within the physical environment

ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES:
❖ “Maglisod kog lihok Ma’am
agi sa akong condition” As
verbalized by the patient
OBJECTIVE CUES:
❖ Discomfort was observed
❖ Restlessness
❖ Limited range of motion
❖ Vital Signs:
• Temperature: 36.9 OC
• Pulse Rate: 85 bpm
• Respiratory Rate: 18 cpm
• Blood Pressure: 100/70
mmHg
At the end of 8 hours of
student nurse – client
interaction, there will be
improved physical mobility as
evidenced by:
1. Client will show relief of
discomfort and restlessness
2. Client will maintain
position of function.
3. Client will increase
strength/function of
affected and compensatory
body parts.
4. Client will demonstrate
techniques that enable
resumption of activities.
INDEPENDENT:
1. Assess the degree of immobility
produced by injury or treatment
and note the patient’s perception
of immobility.
2. Monitor blood pressure (BP)
with the resumption of activity.
Note reports of dizziness.
3. Encourage the use of isometric
exercises starting with the
unaffected limb.
✓ The patient may be restricted by
self-view or self-perception out
of proportion with actual
physical limitations, requiring
information or interventions to
promote progress toward
wellness.
✓ Postural hypotension is a
common problem following
prolonged bed rest and may
require specific interventions (tilt
table with gradual elevation to
the upright position).
✓ Isometrics contract muscles
without bending joints or moving
limbs and help maintain muscle
strength and mass.
At the end of 8 hours of student
nurse – client interaction, the
goal was:
1. Met- patient shows relief of
discomfort and absence of
restlessness observed.
2. Partially met- patient maintains
position of function slightly.
3. Partially met- after treatment
and therapy patient slightly
increases strength/function of
affected and compensatory
body parts.
4. Met- Patient demonstrates
techniques that enable
resumption of activities.

✓ Useful in maintaining a
4. Provide footboard, wrist splints, functional position of
trochanter, or hand rolls as extremities, hands, and feet and
appropriate. preventing complications
(contractures, foot drop).

5. Reposition periodically and
encourage coughing and deep-
breathing exercises.
6. Teach the patient and significant
others (SO) about the use of
analgesics and instruct
nonpharmacological pain
management such as imagery,
relaxation, and distractions.
COLLABORATION:
Consult with a physical,
occupational therapist, or
rehabilitation specialist.
Consult with a nutritionist to
provide a diet high in proteins,
carbohydrates, vitamins, and
minerals, limiting protein content
until the first bowel movement.
✓ Prevents or reduces the incidence
of skin and respiratory
complications (decubitus,
atelectasis, pneumonia).
✓ Effective pain intervention will
enhance the patient’s ability to
engage in appropriate activity
and exercises.
✓ Useful in creating individualized
activity and exercise programs.
The patient may require long-
term assistance with movement,
strengthening, and weight-
bearing activities.
✓ In the presence of
musculoskeletal injuries,
nutrients required for healing are
rapidly depleted, often resulting
in a weight loss of as much as 20
to 30 lb (9kg to 13 kg) during
skeletal traction. This can have a
profound effect on muscle mass,
tone, and strength.
NURSING DIAGNOSIS: Risk for Fall r/t loss of skeletal integrity (fractures in tibia/fibula right)

ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES:
❖ “ Maglisod kog lihok
Ma’am dayun mahadlok ko
basin mahulog ko sa
higdaanan Ma’am” As
verbalized by the patient
OBJECTIVE CUES:
❖ dizziness or lightheadedness. 2. Client will maintain
❖ Limited range of motion
❖ Vital Signs:
• Temperature: 36.9 C O
• Pulse Rate: 85 bpm
3. Client will demonstrate body
• Respiratory Rate: 18
cpm
• Blood Pressure: 100/70
mmHg
At the end of 8 hours of student
nurse – client interaction, Risk
for fall is eliminated and safety
measures were maintained as
evidenced by:
1. Relief of dizziness or
lightheadedness
stabilization and alignment
of fracture(s).
3. Support fracture site with
mechanics that promote
stability at the fracture site.
INDEPENDENT:
1. Maintain bed rest or limb
rest as indicated. Provide
support of joints above and
below the fracture site,
especially when moving and
turning.
2. Secure a bed board under
the mattress or place the
patient on the orthopedic
bed.
pillows or folded blankets.
Maintain a neutral position
of the affected part with
sandbags, splints, trochanter
roll, footboard.
4. Review follow-up and serial
X-rays.
At the end of 8 hours of student
✓ Provides stability, reducing nurse – client interaction, the
the possibility of disturbing goal was:
alignment and muscle
spasms, which enhances 1. Met- patient shows relief of
healing. discomfort and absence of
lightheadedness
✓ A soft or sagging mattress 2. Met-Patient was able to
may deform a wet (green) maintain stabilization and
plaster cast, crack a dry alignment of fracture(s).
cast, or interfere with
traction pull.
3. Partially met- Patient
✓ Prevents unnecessary demonstrates body
movement and disruption of mechanics that promote
alignment. Proper stability at the fracture site.
placement of pillows also
can prevent pressure
deformities in the drying
cast.
✓ Provides visual evidence of
proper alignment or
beginning callus formation

5. Position the patient, so that
appropriate pull is
maintained on the long axis
of the bone and provide
health teaching about proper
body mechanics.
and healing process to
determine the level of
activity and need for
changes in or additional
therapy.
✓ Promotes bone alignment
and reduces the risk of
complications (delayed
healing and
nonunion).Body mechanics
promotes stability at the
fracture site
1. Carry out the doctor's order (e.g. kardex, meds chart, tickets)
2. Carry out the doctor's order (e.g. kardex, meds chart, tickets)