Nursing Care Plan

Patient’s Initial: JB Chief Complaint: Gunshot wound L leg Area of

exposure: CLMMRH
Room/Ward: Orthopedic Ward Diagnosis: Fx open type 111a, complete comminuted p/3-M/3 Fibula L Clinical
Instructor:
Age: 16 y/o Attending Physician: Dr. Flores

General Objective: To promote optimal activity: exercise, rest and sleep

Cues Nursing Rationale Specific Interventions Rationale Evaluation
Diagnosis objective
Subjective: Impaired A limitation in Within 2 days Independent: After 2 days
The patient Physical Independent, of rendering *Help client > The longer a of duty the
verbalizes “ Mobility purposeful nursing achieve client is goal was
nabudlayan ko related to physical intervention mobility and immobile, the partially met.
mag giho-giho, pain/discomfo movement of the patient start walking longer it takes to
bisan rt. the body or of will verbalize as soon as regain strength,
pagpangihi ko one or more understandin possible if not balance, and
gapabulig pa ko extremities. g of situation contraindicate coordination.
kay tatay and individual d.
tungod limitado Physical treatment > Feelings of
ang pag hulag agent regimen and *Note frustration/powerl
ko kay naga ↓ safety emotional/beh essness may
sakit daun ang Caused measures. avioral impede
parte sang tiil fracture by responses to attainment of
ko nga naigo damaging the problems of goal.
sang bala tissue and immobility.
tungod sini bone of the
nagakawad an left leg fibula *Instruct in >for position
nako gana mag ↓ the use of side transfers
giho.” Lead to rails..
“indi man ko experience
maka tulog gid severe Collaborative:
mayo kag pain/discomfo *Observe for > Pain limits
makapahuway rt and if possible mobility and is
tungod sang ↓ treat pain often
sitwasyon ko. Resulted to before exacerbated by
impairment of activity. movement.
Objective: movement. Ensure that
  Limited client is not
range of over sedated.
motion >Techniques
 Difficulty *Consult with such as gait
turning Physical training, strength
 Slowed Reference: therapy for training, exercise
movemen Nursing further to improve
t Pocket Guide evaluation, balance and
 Postural by Marilyn E strength coordination can
instability Doenges training, gait be very helpful to
Temp: 38.2◦c training, and rehabilitate
Hematocrit development client.
o.39l/l of a mobility
Hemoglobin plan.
125g/l

Patient’s Initial: JB Chief Complaint:

Gunshot wound L leg Room/Ward: Orthopedic Ward
Diagnosis: Fx open type 111a, complete comminuted p/3-M/3 Fibula Age: 16 y/o
Date of Exposure: Aug. 4-5, 2009 Attending Physician: Dr. Flores
Clinical Instructor: Mr. Alberto Mahinay, RN
Area of exposure: CLMMRH

Laboratory Examination

Data Normal Lab. Results Implications Nursing

Values considerations
*Hematocrit 0.40 -0.54l/l 0.39l/l ↓ Hematocrit >Encourage
concentration patient to
in the blood; take with
hemodilutiona meal green
l. leafy
 *Hemoglobin 130-180g/l 125g/l vegetables..
↓Hemoglobin
concentration >Instruct
in the blood; patient to
↓ carrying take FeSO4
Oxygen together with
capacity on vitamin C.
the blood >Promote
rest sleep and
Activity as
tolerated.

Patient’s Initial: JB Chief Complaint:

Gunshot wound L leg Room/Ward: Orthopedic Ward
Diagnosis: Fx open type 111a, complete comminuted p/3-M/3 Fibula Age: 16 y/o
Date of Exposure: Aug. 4-5, 2009 Attending Physician: Dr. Flores
Clinical Instructor: Mr. Alberto Mahinay, RN
Area of exposure: CLMMRH

Discharge Plan
Problem Health Teaching Level
Hygiene::  Have a cane / crutch  Promotive/Preventive
 Daily Bed bath Risk for fall/further always when walking
 Oral Care injury and avoid walking on
a rough/rocky road.
  Wound Care  See physical  Rehabilitative
therapist for
evaluation and
treatment.
Activity:
 Walking with crutch as  Someone accompany  Preventive
tolerated, everyday you on walking
 Rest and Sleep regularly Anemia
 Eat more green leafy  Promotive
 Attending mass every vegetables
Sunday  Compliance to
regimen  Curative
 Avoid sleeping late at  Preventive
night
Diet:
 Foods Rich in Ca + Vit. D.
 Instruct relatives to  Promotive
 Adequate CHO, Chon and fat assist the patient in
intake Self Care
dependence doing ADLs  Preventive
 Eat lots of vegetable &  Allow patient to
Fruits function  Curative
independently if
possible
 Compliance to
regimen for fast
recovery
Instruction: Return 3-5days
after discharge for ff. check up.
See physician therapist.
Compliance to bring home
medications.
Ex.FeSO4 Capsule 2x a day for 2
weeks

PROBLEM LIST
Patient’s Initial: JB Chief Complaint:
Gunshot wound L leg Room/Ward: Orthopedic Ward
Diagnosis: Fx open type 111a, complete comminuted p/3-M/3 Fibula Age: 16 y/o
Date of Exposure: Aug. 4-5, 2009 Attending Physician: Dr. Flores
Clinical Instructor: Mr. Alberto Mahinay, RN
Area of exposure: CLMMRH
Physiologic
Behavioral
Cues Problems Actual Potential Actual Potential
Subjective:
The patient Risk for
Pain Pain related to Risk for acute Stress overload
verbalizes “ disorganized
Injuring confusion related related to 4 days
nabudlayan ko behavior related
Agent(Physical) to pain episodes agony of pain.
mag giho-giho, to pain
bisan pagpangihi
ko gapabulig pa
Sleeplessness
ko kay tatay
Sleep deprivation Risk for fall r/t Impaired social
tungod limitado Risk for spiritual
r/t physiological fatigue ability interaction r/t
ang pag hulag ko distress r/t
responses of the need to rest.
kay naga sakit complicated
body toward
daun ang parte health condition.
health condition
sang tiil ko nga
Low hemoglobin
naigo sang bala
& hematocrit Risk for activity Ineffective denial
tungod sini
level Ineffective tissue intolerance r/t r/t personal and
nagakawad an Risk for
perfusion r/t to decrease oxygen family value
nako gana mag situational low
decrease carrying capacity system
giho.” self-esteem r/t
hemoglobin of the blood
“indi man ko unrealistic self
concentration in
maka tulog gid expectation.
blood
mayo kag
makapahuway
tungod sang
sitwasyon ko.
Objective:
 Limited
range of
 motion
 Difficulty
turning
 Slowed
movement
 Postural
instability
Hematocrit
o.39l/l
Hemoglobin 125g