ASSESSMENT

NURSING
DIAGNOSIS

BACKGROUND
KNOWLEDGE

PLANNING

NURSING
RESPONSIBILITE
S

EVALUATION

S>
medyo
nangangalay na
namamanhid ang
pakiramdam ko
lalo na sa mga
binti ko as
verbalized by the
patient
O>
The pt
manifested:
(+) restlessness
and irritability
(+) numbness on
lower extremities
(+) guarding
behavior

Vital signs as
follows:
Temp- 36.3 C
PR-97bpm
RR-19bpm
BP-110/70 mmHg
The pt. may
manifest:
(+) moaning and
crying

Impaired comfort
related to tissue
trauma and
muscle spasm
secondary to
fracture

Impaired comfort
perceived lack of
ease and relief.
The client has a
surgical
management of
skeletal traction
which alters his
comfort because
of immobilization
and presence of
pain

Short term>
After 4 hours of
appropriate
nursing
intervention the
patient will
report a
decrease feeling
of spasm on
lower extremities

Independent:
Explain all the
procedures to the
patient
-to be aware to
different procedure
that will be done to
him and to also
lessen his anxiety
Assess vital signs
and record
-to obtain baseline
data
Evaluate clients
ability to provide
self-care
-self-care places an
important part in
maintaining
integrity of the
skin
Encourage the
patient to increase
fluids
-to prevent
dehydration
Encourage the
patient to do ROM

After 4 hours of
appropriate
nursing
intervention the
patient shall
report a
decrease feeling
of spasm on
lower extremities

Changes in
sleeping pattern
Fatigue

exercise
-to maintain
muscle and bone
integrity and to
prevent muscle
atrophy on both
lower and upper
extremities
Review knowledge
base and note
coping skills that
have been used
previously
-to change
behavior and
promote well-being
Provide ageappropriate
comfort measures
like change of
position
-to promote nonpharmacological
pain management
Encourage/plan
care to allow
individually
adequate rest
periods
-to prevent fatigue

Schedule activities
for periods when
client has the most
energy
-to maximize
participation

Dependent:
Assists client to
use and modify
medication
regimen
-to make best use
of pharmacological
pain or symptom
management
Collaborative:
Collaborate in
treating or
managing medical
condition involving
oxygenation,
electrolyte balance
and hydration
-to promote
physical stability
Discuss
intervention such

as TT or
therapeutic touch
-to
nonpharmacologic
al pain
management
Make appropriate
referrals to
available support
groups and service
organization
Discuss potential
complications and
possible need for
medical follow-up
or alternative
therapies
-timely recognition
and intervention
can promote
wellness
Collaborate with
others when client
expresses interest
in counseling
-to enhance
emotional and
spiritual comfort

ASSESSMENT

NURSING
DIAGNOSIS

BACKGROUND
KNOWLEDGE

PLANNING

NURSING
RESPONSIBILITE
S

EVALUATION

S>
sumasakit siya
minsan lalo na
kapag nagagalaw
ko as verbalized
by the patient
O>
The pt.
manifested:
-restlessness and
irritability
-facial grimace
-guarding
behavior
-wincing upon
movement
Vital signs as
follows:
Temp- 36.3 C
PR-97bpm
RR-19bpm
BP-110/70 mmHg
Pain scale of 6/10
The pt. may
manifest:
-(+) moaning
and crying
-Altered ability to
continue
previous

Acute pain
related to
movement of
bone fragments
and injury to the
soft tissue
secondary to
surgery

Acute pain is
describe as
unpleasant
sensory or
emotional
experience
associated with
actual or
potential tissue
damage or injury
as lasting from
seconds to 6
months. In cases
of fracture, pain
is continuous and
increasing in
severity until
bone fragments
are immobilized.
In this type of
fracture, the
main surgical
management is
skeletal traction
to hold the bone
fragments in
position until
solid bone
healing occur

Short term>
After 8 hours of
appropriate
nursing
intervention the
patient will
reduced pain
scale from 6 to
4/10

Independent:
Assess for referred
pain
-to help determine
possibility of
underlying
condition or organ
dysfunction
requiring
treatment
Maintain
immobilization of
affected part by
means of bed rest
and traction
-to relieve pain and
prevents bone and
displacement and
extension of tissue
injury
Elevate and
support injured
extremities
-promotes venous
return, decreases
edema and may
reduce pain
Elevate bed covers
and keep linens off

After 8 hours of
appropriate
nursing
intervention the
patient shall
reduced pain
scale from 6 to
4/10

activities
-Fatigue
-Anorexia
-Atrophy of
involved muscle
groups

toes
-maintain body
warmth without
comfort due to
pressure of bed
clothes on affected
area
Encourage patient
to discuss
problems related
to injury
-helps alleviate
anxiety. Patient
may feel need to
relieve the
accident
experience
Medicate before
the care activities.
let the patient
know it is
important before
pain becomes
severe
-promotes muscle
relaxation and
enhances
participation
Perform ROM
exercises

-maintain strength
and mobility of
unaffected muscle
and facilitate
resolution of
inflammation in
injured tissues
Provide alternative
comfort measures
like gradually
changing of
position
-improves general
circulation and
reduces areas of
local pressure and
muscle fatigue
Provide emotional
support and stress
management
-refocuses
attention,
promotes sense of
control and may
enhance coping
abilities in the
management of
the stress of
traumatic injury
and pain, which is
likely to persist for

an extended period
Identify diversional
activities foe
patient age,
physical abilities
and personal
preferences
-prevents
boredom, reduces
muscle tension and
can increase
muscle strength,
may enhance
coping abilities
Investigate any
reports of unusual
or sudden pain or
deep, progressive
and poorly
localized pain
unrelieved by
analgesics
-may signal
developing
complications like
infection, tissue
ischemia,
compartmental
syndrome
Dependent:

Administer
analgesic as
indicated
-to maintain
acceptable level
of pain. Notify the
physician if
regimen is
inadequate to
meet pain control
goal

Collaborative:
Collaborate in
treatment of
underlying
condition or
disease processes
causing pain and
proactive
management of
pain
-to assess the
general condition
of the patient
Provide for
individualized
therapy or exercise
program that can

be continued by
the client after
discharge
-to promote active
role and enhance
sense of control

Learning derived:
I can say that this rotation is one of my best experiences, not just because of my new group mates but also I
get the opportunity to find new cases of diseases that would widen my insight on various condition that would help
me prepare for my future as a nurse. This study is done deductively and was conducted by our group to evaluate
and get more information to understand the condition of our patient. The case we handled made us further
comprehend about his condition. The study taught us to give all the appropriate management in the condition of our
patient. I realized that what is important in our duty is to have a heart to our patient. A nurse play an integral role in
the healthcare system. This is why they have been correctly referred to as the heart of the healthcare. As a nurse we
have the opportunity to heal the heart, mind, soul and body of our patients. they may not remember our name but
they will never forget the way you made them feel.