CUES

NURSING DIAGNOSIS

BACKGROUND KNOWLEGDE

OBJECTIVES OF CARE

PLAN OF INTERVENTIONS

RATIONALE

EVALUATION SCHEME

Subjective: Masakit yung kaliwang paa ko Objective > skeletal traction on left tibia >long arm cast and bandage on right arm, (+) pitting edema +1 > Rated felt pain at traction site w/ Pain scale 4/10(were as 0no pain, 1-3 mild, 4-7 moderate, and 8-10 severe pain) VS as of 8am T 36.2 C PR 90 bpm 2+ RR 20 cpm regular bilateral chest expansion BP 120/80 mmHg

Acute pain r/t tissue trauma and reflex muscle spasms secondary to Multiple gunshot wound

External device attached (Skeletal traction)

Tissue Injury Inflammatory response COX-2 will be released to produce Prostaglandin mainly Prostaglandin E2 Also chemical mediator such as Bradykinin will also be released to promote vasodilation of blood vessels Pain will be produced

Long Term P1: After 10-20 days, the pt will be able to fully recover from the operation as evidenced by doing ADL like walking around the house and doing household chores. Short term P2: Within the shift, the pt will report relieve of pain from(4/10) moderate(4-7) to mild(1-3).

> to initiate NPI

> to establish rapport

> to monitor Vital signs

> for continuous pt monitoring

> to assess pain, noting locations, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.

> Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention. > Being informed about the progress of situation provides emotional support, helping to decrease

Long term: Reassessmen t of general health condition of pt and demonstration of ADL he can perform

E: Reassessmen t of pain level of pt.

> to provide accurate, honest information to patient or significant others.

anxiety. > to provide pharmacologic agent to reduce pain as prescribed by the physician (Mefenamic acid and Celecoxib) >to help in reduction of pain

>to encourage early ambulation if possible

> Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort.

> Encourage use of relaxation > To be able to techniques such as deeprelieve muscle breathing exercises. and emotional tension of the patient; To enhance sense of control and may improve coping abilities