Name of Student: Mary Claire Joy Pescadero Section and Group number: 4C Group 5

Assessment Nursing Diagnosis (Rationale)

NURSING CARE Nursing
Desired
PLANIntervention Justification Evaluation
Cues Pathophysiologic / Outcome
Schematic Diagram
Subjective: Risk for injury related to pain Predisposing Factor: After 8 hours of Nursing Independent Interventions: After 8 hours of
Patient verbalized, and discomfort, altered Age: 29 years old Intervention, the 1. Monitor vital sign. 1. This serve as a baseline Nursing Intervention,
“Nurse gasakit akon mobility and decreased bone Gender: Male patient and data. the patient and
tuhod kis.a kabudlay function of the patient significant other will be significant other was
magiho.” Precipitating Factor: able to: 2. Assess the client’s 2. Pain may manifest as an be able to:
Lifestyle- Drinking description of pain. ache, progressing to sharp
Pain Scale of 8/10. Playing Sports- Football Short Term Goal: pain when the affected area is
A. Demonstrate stable brought to full weight-bearing A. Demonstrate
Twists or turns their upper vital signs. or a full range of motion stable vital signs as
Definition: leg while their foot is (ROM). follows, T: 36.2 C, PR
At risk for injury as a result planted and their knee is of 90 bpm, RR of 18
of environmental conditions bent. 3. Assist client with active and 3. Maintains and enhances cpm and BP of 130/80
Objective: interacting with the passive ROM exercises and muscle strength, joint mmHg. Goal Met
Guarding sign individual’s adaptive and Abduction external rotation isometrics as tolerated. function, and endurance.
Facial grimace defensive resources. violence on a flexed-weight B. Identify measures to
Restlessness bearing knee prevent injury 4. Encourage client to lose 4. Excess weight adds extra B. Identified measures
weight to decrease stress on stress on the joints, which can to prevent injury and
Vital Signs: Tear in the meniscus weight-bearing joints. accelerate joint cartilage patient verbalized that
T=36.5 C deterioration. “makapyot gd ko mau
PR=110 bpm Source/Reference Pain nurse kag mangau
RR=24 cpm, Nurse’s Pocket Guide. 5. Instruct the use of adaptive 5. This will keep the joints bulig kung mapa cr
BP=145/85 mmHg Edition 11 by Marilynn mobility equipment such as mobile, promote safety, and ko.” Goal Met.
Doenges, Mary Frances Signs and Symptoms: Long Term Goals: walkers, canes, and crutches maintain a high quality of life.
Moorhouse and Alice Murr  Pain C. Free from injuries as indicated. 6. Help the patient relax and in C. Free from injuries
Strength :  Stiffness and swelling relieving their pain. by following the
Good family support  Catching or locking of instructions given by
Willing to adhere to your knee the nurse and tries
the treatment  The sensation of your 6. Instruct the client 6. Helps prevent accidental not to overdo things.
Patient complies to knee giving way regarding safety measures: injuries and falls. Goal Met.
his medications  Inability to move your  Raised chairs and toilet
knee through its full seat
range of motion  Use of handrails
 Accurate use of mobility
Weakness: Acute pain related to equipment and
Lack of knowledge twisting of leg as evidenced wheelchair safety.
regarding torn by pain scale of 8/10,
meniscus verbalization of pain, facial
grimace and restlessness Dependent Interventions:
1. Administer prescribed 1. This could promote healing
medications. of the patient and help relieve
pain felt by the patient.
Reference:
Meniscus Tears. (nd).
Retrieved from
https://orthoinfo.aaos.org/e
n/diseases--conditions/meni
scus-tears/

Name of CI: Miss Marisse Arroyo RN, MN Area of Exposure: CLMMRH Orthopedics