NCP

PRIORITIZATION

Assessment
Subjective:
Ang sakit ng
binti ko as
verbalized by
the patient
rates pain as
8/10 using
pain scale
Objective:
a.
uses
guarding
b.
behavior
with rigid
c. tone
muscle
on surroudin
area of
d.
affected site
skin
e.
surrounding
fracture is
warmf.to
touch
redness on
g.
and under
affected site
slightly
tender to
touch

Diagnosis
Acute pain
related to
bone
fragment
movement
as
evidenced
by
complaints
of pain

acute pain

Planning
After series of
nursing
intervention, the
patient will be
able to verbalize
that pain has
been
relieved/decrease
d; display relaxed
manner and
demonstrate use
of relaxation skills
and diversional
activities as
indicated for
individual
situation.

Intervention
Assess for
location,
intensity,
quality, and
precipitating
factors

impaired physical mobility

impaired gas exchange
impaired skin Integrity
self-care deficit

Have the
patient rate
pain intensity
using a pain
rating scale

Rationale
Identifying
these will
assist in
accurate
diagnosis
and
treatment;
most
patients
who
experience
fractures
experience
some pain,
especially
with
movement
Provides a
more
objective
description
of the level
of pain
Allows
detection of
early signs
of
neurovascul
ar
dysfunction

Evaluation
After series of
nursing
intervention,
the patient
was able to
verbalize that
pain has been
relieved,
displayed
relaxed
manner and
demostrated
use of
relaxation
skills and
diversional
activites,
patient also
rated pain as
3/10 using
pain scale.

risk for peripheral neurovascular dysfunction

risk for trauma

Assess status
of affected
extremity,incl
uding pain at
injury site,
tenderness to
touch,
temperature,
and edema
Move the
patients
extremity
gently and
cautiously

Administer
analgesics as
ordered on a
regular
schedule; do
not allow pain
to get intense

Elevate
fractured
extremity
Assess for

Movement
of affected
extremity
causes
pain; careful
movement
provides
support for
the painful
area
Decreased
pain will
improve the
patients
ability to
participate
in physical
therapy
activities
required for
improved
mobility
Elevation
will reduce
edema

Assessment

Subjective data:
nahulog ako
pababa sa hagdan
kaya hindi ako
ngayon makalakad
as verbalized by the
patient.
Objective data:
Limited
range of
motion
Decreased
muscle
strength
Slowed
movements
Slight facial
grimace
when
moving
Limited
ability to do
gross and
fine motor
skills
Functional
level: 3

Diagnosis

Planning

Impaired physical
mobility related to
discomfort and
pain secondary to
fracture

After series of
nursing
interventions, the
patient will
verbalize
willingness to and
demonstrate
participation in
activities, verbalize
understanding of
situation/ risk
factors and
individual
treatment regimen
and safety
measures,
maintain position
of function and
skin integrity as
evidenced by
absence of
decubitus ulcers

Intervention

Note factors
affecting
current
situation and
potential time
involved.

Assess degree
of pain,
listening to the
client
description
about manner
in which pain
limit mobility.
Assess clients
developmental
level, motor
skills, ease
and capability
of movement,
posture and
gait.
Determine
history of falls
and
relatedness to
current
situation.

Encourage
participation
on diversional
or recreational
activities.

Instruct patient

Rationale

Identifies
potential
impairments
and
determines
type of
interventions
needed to
provide for
clients safety.

To determine
presence of
characteristic
of clients
unique
impairment
and to guide
choice of
intervention.
Client may be
restricting
activity
because of
weakness or
debilitation,
actual injury
during fall, or
from
psychological
distress that
can persist
after a fall.
Provides
opportunity
for release of
energy,
refocuses or
self -worth
and aids in
reducing
social
isolation.

After
nursi
interv
patie
verba
willin
demo
partic
activi
verba
unde
situa
facto
meas
main
posit
and s
with n
of de
ulcer

in assisting in
active or
passive range
of motion
exercises of
affected and
unaffected
extremities.

Provide foot
board.

Assist with or
encourage
self-care
activities

Reposition
periodically.

Encourage
increased fluid
Intake and
nutritious
foods.

Increases
blood flow to
muscle and
bone to
improve
muscle tone,
maintain joint
mobility;
prevent
contractures
or atrophy
and calcium
resorption
from disease.
Useful in
maintaining
functional
position of
extremities,
preventing
complications
Improve
muscle
strength and
circulation,
enhances
patient
control in
situation and
promotes
self- directed
wellness.
Prevents or
reduces
incidence of
skin
complication.
Promotes
well-being
and
maximizes
energy
production.

Assessment
Subjective:
lagi nalang masakit
yung ulo ko
pagkagising ko as
verbalized by the
patient.
Objective:
Confusion
Restlessness
Irritability
Pale skin
color of the
feet
Chest pain
ABG level of
93%
Vital signs of:
T:
PR:
RR:
BP:

Diagnosis

Planning

Impaired Gas
exchange
related to altered
blood flow

After series of
nursing intervention
my patient will be
able to
demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within clients usual
parameters and
absence of
symptoms of
respiratory distress.

intervention
Note
respiratory
rate, depth,
use of
accessory
muscles,
pursed lip
breathing;
areas of
pallor/cyanosi
s, such as
peripheral
(nailbeds)
versus central
(circumoral)
or general
duskiness.
Monitor vital
signs and
cardiac
rhythm
Assess level
of
consciousnes
s and
mentation
changes

Assist with
incentive
spirometry
Evaluate
pulse
oximetry and
capnography

Rationale
Provides
insight into
work or
breathing and
adequacy of
alveolar
ventilation.

All vital signs

are impacted
by changes in
oxygenation
Decreased
level of
consciousnes
s can be an
indirect
measurement
of impaired
oxygenation,
but it also
impairs ones
ability to
protect the
airway,
potentially
further
adversely
affecting
oxygenation.
Increases
available o2
for optimal
tissue
oxygenation.
To determine
oxygenation
and levels of
carbon
dioxide
retention

 Elevate head
of the bed
and position
client
appropriately
Encourage
frequent
position
changes and
deep
breathing and
coughing
exercises.
Handle
injured
tissues and
bones gently,
especially
during first
several days.

Elevation or
upright
position
facilitates
respiratory
function by
gravity.
Promotes
optimal chest
expansion
and oxygen
diffusion.

This may
prevent the
development
of fat emboli
(usually seen
in first 1272hr), which
are closely
associated
with fractures
especially of
the long
bones and
pelvis

Assessment
Subjective:
Reports of pain
in the affected or
surrounding
area (left lower
leg)
Objective:
Destruction of
skin layers
Broken tibia in
the lower left
extremity sticks
out through the
skin.
(Compound
Fracture)

Diagnosis
Impaired Skin
Integrity related to
traumatic injury
secondary to open
fracture as
evidenced by
destruction of skin
layers

Planning

Intervention

After series of
Identify
nursing
underlying
interventions, the
condition or
patient will verbalize
pathology
relief of discomfort;
involved.
Demonstrate
Determine
behaviors/techniques
clients age and
to facilitate healing
developmental
as indicated;
factors or ability
maintain optimal
to care for self.
nutrition and physical
well-being;
participate in
Evaluate clients
prevention measures
skin care
and treatment
practices and
program and
hygiene issues.
verbalize feelings of
increased selfesteem and ability to
manage situation.
Determine
nutritional status
and potential for
delayed healing

Rationale
To assess
causative or
contributing
factors.
To determine the
risks, sensitivity
of skin and level
of
responsiveness
to pain
sensations
Ineffective
hygiene can
result in serious
skin impairment
and discomfort.

To assess if
malnutrition
is/could be a
contributing
factor
To identify risk
for injury and
safety
requirements.

Evaluate client
with impaired
cognition,
developmental
delay, need for
or use of
restraints, longterm immobility.
Note presence of May impact
compromised
clients self-care
mobility,
as relates to skin
sensation,
care.
vision, hearing or
speech.
Assess blood
To provide
supply and
comparative
sensation of skin
baseline and
surfaces and
opportunity for
affected area on
timely
a regular basis.
intervention
when problems
are noted.
Review
Albumin less
laboratory
than 3.5
results pertinent
correlates to
to causative
decreased

Af
nu
in
pa
re
D
be
to
as
m
nu
we
pa
pr
an
pr
ve
in
es
m

factors.

Perform routine
skin inspections
describing
observed
changes.
Determine
degree and
depth of injury or
damage to
integumentary
system.
Photograph the
affected area, as
appropriate.

Determine
clients level of
discomfort.
Ascertain
attitudes of
individual or
significant others
about condition.
Note
misconceptions.
Inspect skin on a
daily basis,
describing
characteristics
and changes in
the affected
area.
Periodically
measure and
photograph the
affected area
and observe for
complications.
Avoid or limit use
of plastic
material.
Remove wet and
wrinkled-linens

wound healing
and increased
frequency of
pressure ulcers.
For determining
the need for
change of
interventions.
To assess extent
of involvement.

To document
status and
provide visual
baseline for
future
comparisons.
To clarify
intervention
needs and
priorities.
Identifies areas
to be addressed
in teaching plan
and potential
referral needs.

To assist client
with correcting or
minimizing
condition and
promote healing.

To monitor
progress of
healing.

Moisture
potentiates
breakdown.

promptly.
Reposition client
on regular
schedule,
involving client in
reasons for and
decisions about
times and
positions.
Encourage early
ambulation or
mobilization.

Provide optimum
nutrition,
including
vitamins and
protein.

Review
importance of
health, intact
skin, as well as
measures to
maintain proper
skin functioning.
Assist the client
or significant
others in
understanding
and following
medical regimen
and developing
program of
preventive care
and daily
maintenance.

To enhance
understanding
and cooperation.
Lessens constant
pressure on same
areas and minimizes
risk of skin
breakdown.
Promotes
circulation and
reduces risks
associated with
immobility.
To provide a
positive nitrogen
balance to aid in
skin and tissue
healing and to
maintain general
good health.
The
integumentary
system is the
largest
multifunctional
organ of the
body.
Enhances
commitment to
plan, optimizing
outcomes.

Assessment

Diagnosis

Planning

Intervention

Subjective:
Reports of pain
and discomfort
on the affected
lower extremity
Objective:
With
musculoskeletal
impairment on
left lower leg
Impaired
physical
mobility
Environmental
barrier;
[mechanical
restriction
skeletal traction]

Self Care Deficit

in bathing,
dressing and
toileting related to
impaired
immobility as
evidenced by
traction application

After series of
nursing
interventions, the
patient will identify
individual areas of
weakness or
needs; verbalize
knowledge of
healthcare
practices;
demonstrate
techniques and
lifestyle changes to
meet self-care
needs; perform
self-care activities
within level of own
ability and identify
personal and
community
resources that can
provide
assistance.

Note
concomitant
medical
problems or
existing
conditions that
may be factors
for care.
Identify degree
of individual
impairment and
functional level
according to
scale.
Note whether
deficit is
temporary or
permanent,
should
decrease or
increase with
time.
Provide
accurate and
relevant
information
regarding
current and
future needs.
Promote clients
or significant
others
participation in
problem
identification
and desired
goals and
decision
making.
Active listen
clients and
significant
others
concerns.

Rationale
To identify
causative or
contributing
factors.

To assess degree
of disability.

So that client can

incorporate into
self-care plans
while minimizing
problems often
associated with
change.
Enhances
commitment to
plan, optimizing
outcomes, and
supporting
recovery and
health promotion.

Exhibits regard for

clients values and
beliefs, clarifies
barriers to
participation in self
care, provides
opportunity to work
on problem-solving
solutions and to
provide
encouragement

After s
nursin
interve
patien
individ
weakn
needs
knowl
health
practic
demo
techni
lifesty
meet
needs
self-ca
within
ability
identif
and co
resou
provid

 Practice and
promote shortterm goal
setting and
achievement.

Ask client or
significant
others for input
on bathing
habits or
cultural bathing
preferences.
Obtain hygiene
supplies for
specific activity
to be performed
and place in
clients easy
reach.
Provide for
adequate
warmth.

Provide for or
assist with
grooming
activities on a
routine,
consistent
basis.
Encourage
participation,
guiding clients
hand through
tasks, as
indicated.
Ascertain that
appropriate
clothing is
available.

Dress client or

and support.
To recognize that
todays success is
as important as
any long-term goal,
accepting ability to
do one thing at a
time and
conceptualization
of self-care in a
broader sense.
Enhances selfesteem, while
respecting
personal and
cultural
preferences.

To provide visual
cues and facilitate
completion of
activity.

Certain individuals
are prone to
hypothermia and
can experience
evaporative cooling
during and after
bathing.
Experiencing the
normal process of
a task through
established routine
and guided
practice facilitates
optimal relearning.

Clothing my need
to be modified for
clients particular
medical condition
or physical
limitations.

assist with
dressing, as
indicated.

Encourage food
and fluid
choices
reflecting
individual likes
and abilities
and that meet
nutritional
needs.
Provide privacy.

Assist with
manipulation of
clothing, if
needed.

Provide or
assist with use
of assistive
equipment.

Review safety
concerns.
Modify activities
or environment.
Assist and
support family
with alternative
placements as
necessary.
Be available for
discussion of
feelings about
situation.

Client may need

assistance in
putting on or taking
off items of clothing
or may require
partial or complete
assistance with
fasteners.
To maximize food
intake.

That may be
indicative of need
for prompt toileting.
To decrease
incidence of
functional
incontinence
caused by difficulty
removing
clothing/underwear.
To promote
independence and
safety in sitting
down or arising
from toilet or for
aiding elimination
when client is
unable to go the
bathroom.
To reduce risk of
injury and promote
successful
community
functioning.
Enhances
likelihood of finding
individually
appropriate
situation to meet
clients needs.
Provides
opportunity for
client/family to get
feelings out in the

Assessment
Subjective:
Manhid ang
pakiramdam
ko sa binti ko
as verbalized
by the patient.
Objective:
Pallor color
of the skin
surroundin
g fractured
area
Skin
surroundin
g affected
site is cool
to touch

Diagnosis
Risk for
peripheral
neurovascula
r dysfunction
related to
possible
nerve
damage due
to instability
of fractured
limb

Planning
After series of
nursing
intervention,patien
t will be able to
experience no
severe pain at
injury site;
patients
peripheral pulses
in his/her lower
leg are papable;
patients lower leg
is warm with
capillary refill brisk
at < 3 seconds
and patients
lower leg remains
at normal color

Intervention
Assess
neurovascular
status of both
extremities
every 1-2
hours or as
ordered:
pulses,
sensation,
temperature,
capillary refill,
and movement
Assess for
signs and
symptoms of
severe pain
unrelieved by
usual
analgesic,
diminished or
absent pulses,
cool extremity,
decreased or
absent
sensation in
the extremity,
loss of normal
color, and
decreased
capillary refill
Monitor vital
signs with
particular
attention to
blood pressure
readings

Maintain cast
and check for
tightness

Check
extremity for
excess edema
or tightness;
ask patient

Rationale
Evaluation
Establishes a After series
of nursing
baseline ad
open and begininterventio
to
then detects
problem-solve n patient
early any
solutions as
complications did not
indicated.
experience
that may
any severe
occur due to
pain at
casting
injury site,
patients
peripheral
pulses in
Unrelenting
his/her
pain not
lower leg
relieve by
are
usual
palpable,
analgesic is
patients
early classic
lower leg is
sign or
compartment warm to
with a
syndrome
capillary
refill of 2
seconds
and the
patients
lower leg
remained
at normal
A patient
color, no
must
edema or
maintain
swelling
sufficient
noted.
blood
pressure in
order to
maintain
perfusion to
the affected
extremity
compartment
s
Casts that
are too tight
may lead to
compartment
syndrome by
causing
undue
pressure on
the
compartment
s of the
extremity
Edema that is
unrelieved
through
elevation
could lead to

Assessment
Subjective:
Reports of pain
and discomfort
on the injured
left lower
extremity.
Objective:
With Skeletal
traction on left
lower extremity
With reduced
muscle
coordination on
the affected left
lower limb
Weakness on
the injured
lower extremity

Diagnosis
Risk for Trauma
related to use of
skeletal traction as
evidenced by loss
of skeletal integrity
of left lower leg

Planning

Intervention

Rationale

After series of
nursing
interventions, the
patient will identify
and correct
potential risk factors
in the environment;
demonstrate
appropriate lifestyle
changes to reduce
risk of injury;
identify resources
to assist in
promoting a safe
environment;
recognize need for
and seek
assistance to
prevent accidents
or injuries.

Determine
factors related
to individual
situation and
extent of risk for
trauma.
Ascertain
knowledge of
safety needs
and injury
prevention, and
motivation to
prevent injury in
home,
community, and
work setting.
Assess
influence of
clients lifestyle
and stress.

Influences
scope and
intensify of
interventions to
manage threat
to safety.
Lack of
appreciation of
significance of
individual
hazards
increases risk of
traumatic injury.

Review history
of accidents,
noting
circumstances.

Review
diagnostic
studies and
laboratory tests
for impairments
or imbalances.
Screen client for
safety
concerns.
Assess for and
report changes
in clients
functional
status. Perform
thorough
assessments
regarding safety
issues when

That can impair

judgment and
greatly increase
clients potential
for injury.
Can provide
clues for clients
risk for
subsequent
events and
potential for
enhanced
safety by a
change in the
people or
environment
involved.
That may result
in or exacerbate
conditions such
as pathological
fracture.
Failure to
accurately
assess and
intervene or
refer regarding
these issues
can place the
client at
needless risk
and creates
negligence
issues for the

Ev

After s
nursing
interve
patient
and co
potenti
in the e
demon
approp
change
risk of
identifi
to assi
promo
environ
recogn
and so
assista
preven
or injur

planning for
client discharge.
Maintain bed
rest or limb rest
as indicated.
Provide support
of joints above
and below
fracture site,
especially when
moving and
turning.
Support fracture
site with pillows
or folded
blankets.
Maintain neutral
position of
affected part
with sandbags,
splints,
trochanter roll,
and footboard.
Discuss
importance of
self-monitoring
of conditions or
emotions that
can contribute
to occurrence of
injury to self.

Identify
community
resources.

healthcare
practitioner.
Provides
stability,
reducing
possibility of
disturbing
alignment and
muscle spasms,
which enhances
healing.
Prevents
unnecessary
movement and
disruption of
alignment.
Proper
placement of
pillows also can
prevent
pressure
deformities in
the drying cast.
Client or
significant
others may be
able to modify
risk through
monitoring of
actions or
postponement
of certain
actions,
especially
during times
when client is
likely to be
highly stressed.
To assist with
necessary
corrections or
improvements
and purchases.