CHAPTER VIII

NURSING CARE PLAN

ACTUAL Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Acute pain

After 30

Independent:

Goal met, as

related to

minutes of

>Maintain

manifested by

movement of

nursing

immobilization of

>Relieves pain and

injured arm.

intervention

affected part by

prevents bone

the patient

means of bed

displacement/extension

will have a
Objectives:

rest, cast, splint,

of tissue injury.

pain scale of

traction.

>Pain scale of

4/10 or less.

>Identify

Subjective:
Nasakit nu
igaraw ko toy
imak.

6/10

diversional

>Grimacing

activities

>Prevents boredom,
reduces muscle tension,

patients scale
of 3/10.

face
>BP- 130/90
mmHg
RR- 19 bpm
PR- 64bpm
To- 36.4C

appropriate for
patient age,
physical abilities,
and personal

and can increase muscle

strength; may enhance
coping abilities.

preferences.
>Elevate and

>Promotes venous

support injured

return, decreases edema,

extremity.

and may reduce pain.

Dependent:
>Administer
medication as
per doctors
order.
Ketorolac 30mg
IV q 8

>Given to reduce pain

and/or muscle spasms

ACTUAL Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTIO

RATIONALE

EVALUATION

Objectives:

Risk for

Long Term

N
Independent:

BP- 130/90

infection

>At the end of

> Assess pin

> May indicate onset

>Goal met.

mmHg

related to

hospital

sites/skin

of local

After hospital

RR- 19 bpm

traumatized

confinement,

areas, noting

infection/tissue

confinement

PR- 64bpm

tissues.

the patient

reports of

necrosis, which can

the patient

Short Term

To- 36.4C

will be free

increased

from

pain/burning

infections

sensation or

lead to osteomyelitis.

infections.

presence of
edema,
erythema, foul
odor, or
drainage
> Damp, soiled casts
> Line cast

can promote growth of

edges with

bacteria.

plastic wrap.
> Hypotension,
confusion may be
> Monitor vital

was free from

seen with gas

signs. Note

gangrene;

presence of

tachycardia and

chills, fever,

chills/fever reflect

malaise,

developing sepsis.

changes in
mentation

>Administer

>Wide-spectrum

medication as

antibiotics may be

per doctors

used prophylactically

order.

or may be geared

Cefalexin 500mg toward a specific

TID

microorganism.Given
prophylactically
because the
possibility of tetanus
exists with any open
wound.

ACTUAL Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Impaired

After 8 hours of

Independent:

physical

nursing

>Determine

>To identify

manifested by

mobility related

intervention the

diagnosis that

contributing

patients

to loss of

patient will

contributes to

factors

understanding

integrity of bone verbalize

immobility.

> May restrict

of the situation

structure.

> Note situations

movement

and individual

the situation and such as fractures

> To assess

treatment

individual

> Determine the

functional

regimen and

>Cast on left

treatment

degree of

mobility

safety

arm

regimen and

immobility in

> To assess

measures and

safety measures,

relation to

presence

participated in

participate in

suggested scale

of complications

ADLs and

ADLs and

> Determine

> To promote

desired

desired activities

presence

optimum level

activities.

of complications

of function and

related to

prevent

Subjective:
Haan ko unay
maygaraw toy
maysa nga
immak.

Objectives:

>Limited r
>BP- 130/90
mmHg
RR- 19 bpm
PR- 64bpm
To- 36.4C

understanding of

Goal met, as

immobility
(pneumonia,
elimination
problems,
decubitus)
> Assist client
reposition self on
a regular
schedule.

complications.