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NURSING CARE PLAN CUES/ NEEDS SUBJECTIVE: “Masaki ang kanang binti ko”, as verbalized by the patient.

Pain range 8/10 as 10 being the highest. OBJECTIVE: *Facial grimace *Protective movement *restlessness *irritability *(+) pain in right leg *with splint and elastic bandage in right leg VS: BP: 120/80 mmHg PR: 82 bpm RR: 19 bpm TEMP: 37.6°C LABS: *X-ray *CT scan Reference: Nurse’s Pocket Guide ed. 11 (pp. 498-503) NURSING DIAGNOSIS Acute pain related to movement of bone fragments. RATIONALE GOAL AND OBJECTIVES After 1 hour of nursing intervention, patient will be able to decrease pain from 8/10 to 3/10 as manifested by: INTERVENTIONS RATIONALE EVALUATION After 1 hour of nursing intervention, goal was met. The patient was able to decreases pain from 8/10 to 3/10 as manifested by: - Report pain is controlled/ relieved. - Relaxed or calmed.

Acute pain caused by unpleasant sensory and emotional experiencing arising from actual or potential tissue damage or described in terms - Report pain is of such damage the controlled/ client is relieved. experiencing pain - Relaxed or calmed.

 Assess verbal/  Useful in nonverbal reports evaluating pain of pain noting choice of location, intervention, intensity and effectiveness of duration. therapy  Monitor vital signs every 4 hours.  Maintain immobilization of affected part by means of bed rest and elastic bandage.  Elevate and support injured extremity.  To have baseline data.  Relieves pain and prevents bone displacement/ extension of tissue injury.  Promotes venous return, decreases edema, and may reduce pain.  Maintains body warmth without discomfort due to pressure of bedclothes on affected parts.  Reduce pain

 Elevate bed covers and keep linens off toes.

 Apply ice

 Reduces pain and discomfort. and swelling. resolution of inflammation in injured tissues .compress on the affected extremity every 30 minutes  Encourage client to discuss problems related to injury.g dolcet) as indicated  Maintain  Perform and strength and supervise passive mobility of or active ROM unaffected exercises on the muscles and unaffected facilitates extremity.  Promote quite and calm environment.  Helps alleviate anxiety.  Administer analgesics (e. Client may feel need to relive the accident experience.  To promote adequate rest and sleep to facilitate pain relief. enhance rest.