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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
injured arm.
intervention
affected part by
prevents bone
the patient
means of bed
displacement/extension
will have a
Objectives:
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
preferences.
>Elevate and
>Promotes venous
support injured
extremity.
Dependent:
>Administer
medication as
per doctors
order.
Ketorolac 30mg
IV q 8
DIAGNOSIS
PLANNING
INTERVENTIO
RATIONALE
EVALUATION
Objectives:
Risk for
Long Term
N
Independent:
BP- 130/90
infection
>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
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
edges with
bacteria.
plastic wrap.
> Hypotension,
confusion may be
> Monitor vital
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
microorganism.Given
prophylactically
because the
possibility of tetanus
exists with any open
wound.
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
immobility.
of the situation
structure.
movement
and individual
> To assess
treatment
individual
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.