Nursing

Cues Nursing Diagnosis Inference Objective Rationale Evaluation

Intervention

Subjective ◊ Impaired physical Blunt Injury Short Term Goal Independent ◊ After 3 days of
mobility of the (foreign object fall) nursing intervention,
◊ “Medyo di pa ako lower extremity r/t ◊ After 3 days of ◊ Assisted with ◊ Necessary to regain goal is met through
makakilos ng gaya external fixator @ L nursing intervention, normal range of normal mobility of leg the regaining of the
dati dahil sa nakakabit leg Injury to tibia/ he demonstrates and motion exercises and to speed recovery. patient’s previous
sa akini” as verbalized Fracture verbalizes proper function of lower range of motion in the
exercises of the lower extremity. leg & demonstrates
Objective extremities & can ◊ Increase patient’s proper exercises for
bleeding from perform activities of ◊ Encouraged use of affected leg. the lower extremities.
◊ c external fixator damaged ends of daily living with progressive activities He also does ADL
@ L leg bone & from minimal assistance. according to level of without discomfort.
surrounding tissue fatigue.
◊ ambulatory

stimulates intense
inflammatory
response

increased capillary
permeability

fluid/cellular
exudation

Edema

Pain

impaired function
 Nursing
Cues Nursing Diagnosis Inference Objective Rationale Evaluation
Intervention

Subjective ◊ Impaired skin Blunt Injury Short Term Goal Independent ◊ After 30 minutes of
integrity r/t surgical (foreign object fall) nursing intervention,
◊ “Nagkapasa-pasa incision ◊ After 30 minutes of ◊ Vital signs monitored ◊ Changes in vitals the goal is met
ako na maliliit, wala nursing intervention, and recorded. signs may indicate through
na ngayon may mga Injury to tibia/ proper skin hygiene is infection. demonstration of
bakas na lan konte,” Fracture demonstrated. proper skin hygiene
as verbalized. ◊ Taught proper ◊ Cleaning the fixator and cleaning care
cleaning and checking will minimize the risk done on the fixator.
Objective bleeding from of the integrity of the for infection.
damaged ends of fixator.
◊ c external fixator bone & from
@ L leg surrounding tissue ◊ Advised to elevate ◊ This controls
affected lower swelling and pain.
◊ ambulatory extremity from time to
breakage in skin time.