University of Cebu – Banilad

College of Nursing
Cebu City

NURSING CARE PLAN

Patient’s Name : Z.P.T. Hospital No. : 30343

Age : 10 years old Room No. : 305
Impression/Diagnosis : Closed Fracture of Distal 3rd of Ulnar & Radius Physician : Dr. Gianetta Lorena A. Gamelo
Secondary to Fall

CLINICAL PORTRAIT PERTINENT DATA

1. History of present illness
1. Assessment (general impression from head to toe) Patient went outside the house and fell accidentally; his right forearm was
Received patient lying on bed, alert, awake, with his right arm forced to the ground, which caused the fracture.
supported with a sling, and an attached intravenous line on his left
arm. 2. Chief complaints
Acute pain related to fracture, as evidenced by verbalization of pain, 7 out of
10.
2. Significant findings 3. Health history relevant to present illness
Xray test (APL) which confirms a closed fracture on the patient’s Patient has no history of illness and is first time to be admitted in the hospital.
right arms’ distal 3rd of ulnar and radius.
4. Vital signs taken during admission:
BP: 110/60 mmHg
PR: 79 bpm
3. Vital signs taken during the nurse’s first contact with the patient. RR: 26 cpm
BP: 90/70 mmHg O2: 94%
T: 36.7%
PR: 79 bpm
RR: 25 cpm 5. Laboratory results regardless of findings
T: 36 degrees Celsius CBC: Eosinophil: 0.2 Urinalysis:
WBC: 14.94 (H) Bacteria: 2-5
O2: 99% Basophil: 0.1 Color: Light Yellow
Protein: (-)
RBC: 5.29 MCV: 76.9 (L) Transparency: Hazy
Hematocrit: 40.7 Blood: (-)
MCH: 26.5 pH: 6.0
Hemoglobin: 14.0 Ketone: (-)
MCHC: 34.4 Specific G: 1.030
Platelet: 465 (H) Glucose: (-)
RDW: 13.0 RBC: 0-2
Neutrophil: 79.7 (H) Leukocyte: (-)
MPV: 9.7 WBC: 2-5
Lymphocyte: 16.0 (L) Bilirubin: (-)
Monocyte: 4.0 Mucus Thread: 2-5
 NURSING GOAL & OUTCOME NURSING ACTIONS & RATIONALE OF NURSING EVALUATION
CUES DIAGNOSIS SCIENTIFIC BASIS CRITERIA NURSING ORDERS ORDERS

Subjective: Goal: Independent:

“sakit akong Acute Pain Bone fractures are After 12 hours of  Assess patient’s level of  To identify patient’s Goal met:
kamot” as Related to common injuries effective nursing pain using a pain scale level of pain for After 12 hours if
verbalized by the Fracture, as that result in intervention, the and document findings appropriate effective nursing
patient. Evidenced by impairment of the patient will verbalize regularly. intervention and for intervention, patient
Verbalization skeleton’s reduction of pain.  Provide a calm and quiet baseline data. was able to show
Objective: of Pain, 7 out mechanical integrity environment to the  To prevent anxiety to reduction of pain by
- Facial of 10. which typically leads Outcome Criteria: patient. the patient. resting comfortably, and
grimace to functional deficits After 12 hours of  Offer comfortable  To promote comfort on stating a pain scale of 2
- Swelling at and pain, especially effective nursing position to prevent pain. the patient’s behalf. out of 10.
right arm in the hand. intervention, the  Educate patient and  To ensure immediate
- Pain at the Therefore, bone patient will describe family about pain management for pain
right arm stability is important. reduction of pain by: management strategies. to reduce anxiety for
- Weakness  Stating a pain the patient.
(Cooper, 2014) scale of 2 out of Dependent:
- Lab Tests: 10.  Administer analgesics as
 Xray – closed  Showing signs of prescribed by the  To promote
fracture at the comfort by resting medical provider. improvement of
distal 3rd of or sleeping. patient’s pain.
ulnar and
Interdependent:
radius of the
right arm.  Communicate with other
healthcare professionals
- Pain scale: to plan a care for the  To provide the care
7/10 patient. that the patient needs.