Nursing Nursing

Cues Inference Objective Rationale Evaluation

Diagnosis Intervention

Subjective Short-term Goal Independent

● “Sumasakit ● Acute Pain ● Acute pain is After 6 days of ● Vital signs ● Alterations from ●Pain is
at kumikirot r/t described as an nursing were monitored normal may be reduced/
ang surgery unpleasant intervention, q 15 minutes signs of infection. controlled
inoperahan AMB sensory or the patient: until stable & Moistened dressings to a
sakin,” as incision emotional dressing was are favorable site tolerable
verbalized. on L arm experience ● verbalizes checked. for microorganism extent as
associated with minimized or to culture. verbalized.
actual or controlled Relieving
Objective potential feeling of ● Assessed LOC & ● One must be methods &
tissue damage pain turned q 2 conscious & awake relaxation
● c incision or injury as hours, to in order to feel techniques
on the L arm lasting from ● verbalizes unoperative pain. Turning of are
(ORIF-treated seconds to 6 methods that side only. position prevent understood
D/3 radius L months. In provide bed sores. &
with bone cases of relief demonstrated
grafting) fracture, pain ● Adjusted ● This is to prevent
is continuous & ● demonstrates constricting diminished
● c increasing in use of bandage & circulatory & nerve
posterior severity until relaxation advised to function & control
cast & bone fragments skills & elevate L arm. swelling of the
bandage on L are diversional site.
arm immobilized. In activities as
this type of indicated for ● Instructed to ● To reduce swelling
● c swelling fracture, the his situation do activities & prevent stiffness
on the L arm main medical such as deep the stated
management is Long-term Goal breathing activities must be
● c pale open reduction exercise, done. Decreased
pink nail with internal After months of coughing lung capacity &
beds @ L fixation nursing exercise, decreased cough
hand (ORIF), wherein intervention, dorsiflexion of efficiency are
the fracture the patient: foot & sitting predisposing
● BP = fragments are exercises. factors to
140/90mmHg reduced & ● is free of respiratory
internal pain on the infections.
fixation surgical site
devices are ● Noted to avoid ● To prevent from
used to hold weight bearing complications on
the bone until allowed. the incision site,
fragment in activities that may
position until extend the cut must
solid bone be avoided.
healing occurs.
● Encouraged to ● This is advised in
void freely. order to prevent
constipation &
fecal impaction.

● Enough rest & ● This promotes

sleep was also healing by reducing
advised. basal metabolic
rate & allowing
oxygen & nutrients
to be utilized for
tissue growth,
healing &
regeneration.

Dependent

● Intake of ● NSAID activity

pain reliever includes modulation
such as of T-cell function,
mefenamic acid inhibition of
& antibacterial inflammatory cell
medications chemotaxis,
such as decreased release
amoxicillin of superoxide
as per doctor’s radicals, or
order & advise. increased
scavenging of these
compounds at
inflammatory sites.
Antibiotics are
used to treat &
prevent infections
caused by
susceptible
pathogens in skin
structure
infections.
 Submitted By :
Jemarie M. Jimenez
Perpetual Help College of Manila

Submitted To :
Mrs. Wilma F. Cusi, RN
Manila Naval Hospital, C.I.