B.

NURSING CARE PLANS

Scientific
CUES Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation
Background
Subjective: Date: June 9,2O1O Date: June 9,2O1O
“Hindi ko na P- Impaired Physical Risk factor:elderly Time: 7am Independent: Shift: 6-1OAM
ginagalaw masyado Mobility Shift: 6-1OAM >assist patient to do  To increase the
kasi masakit ,” as active/passive ROM blood flow to Goal met as
verbalized by the E- related to exercise to affected and muscles and bone to evidenced by
patient. musculoskeletal Accident/Slipped After 30 minutes of unaffected extremities improve muscle tone demonstrating
Objective: impairment rendering nursing flexion/extension
• Limited movement interventions and >observe movement of  To note any of extremities
• Difficulty in S- as evidenced by health teachings, the the client incongruence with and able to care
changing position verbalization of limited bone fracture patient will report of abilities one self by
while lying on bed range of motion. demonstrate bathing himself
• With balanced behaviors that enable >assist client or  To improve muscle and combing
skeletal traction in resumption of encourage client to do strength circulation himself
right leg pain activities such as self care activities like and promote self
• Inability to active and passive bathing directed wellness
perform ADL’s ROM exercise.
VS taken as:  It serves as a baseline
T:36.2oC extremities do not data
RR:26cpm function properly >monitor vital sign
PR: 95bpm To optimize circulation
BP: 13O/9OmmHg >Turn and reposition
to all tissues and
patient
• shows guarding prevent bedsores.
behavior
• irritable at times
 NURSING CARE PLANS
Scientific
CUES Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation
Background
Subjective: P- Impaired Skin Date: June 10,2O1O Independent: Date: June 10,2O1O
s“Nilagyan ng Integrity fracture Time: 8am >examine the skin for  Provide information Shift: 6-1OAM
steinmann pin ” as Shift: 6-1OAM open wound, rashes regarding skin
verbalized by the E- related to bleeding or circulation and Goal Met.
nephew. immobilization After 30 minutes of discoloration problems that may After 30 minutes of
Objective: secondary to BST pain rendering nursing require further nursing intervention
• With steinmann pin interventions and medical intervention the patient was able to
at right distal femur S- as evidenced by health teachings, the identify management
• Difficulty in Steinmann pin patient will identify >remove excess  This would lead to and prevention of
changing position insertion body weakness independent clothing especially the further damage of further skin infection.
while lying on bed management and rough ones the skin
• With balanced prevention of further
skeletal traction skin infection. >give bed bath  To promote good
• VS taken as: immobility hygiene
T:36.6oC RR:23cpm
>reposition frequently
PR: 90bpm  Lessens constant
BP: 12O/9OmmHg pressure on same
prolonged inability in area and minimizes
turning or changing for skin breakdown
position
>assess position of
splint ring of traction  Improper
device positioning may
cause skin
Signs and symptoms
injury/breakdown

impaired skin integrity

 NURSING CARE PLANS
CUES Nursing Diagnosis Scientific Background Objectives Nursing Interventions Rationale Evaluation
Subjective: P- acute Pain Date: June 11, Date: June 11,2O1O
“masakit na masakit na E- related to Bone fracture 2O1O Independent:
ineng ,” as verbalized musculoskeletal Time: 8am >respond immediately  prompt responses to Shift: 6-1OAM
by the patient. impairment Shift: 6-1OAM to complaint of the complaints may result
/fracture patient in decreased anxiety in Goal partially met as
Objective: S- as evidenced Tissue trauma patient evidenced by
• Appears weak: by verbalization of After 20-30 facial grimace of 6/10
patient can not pain and facial minutes of
perform ADL grimace of 10/10 rendering nursing >provide rest periods to  Fatigue on the patient
• Facial grimace of activation of pain receptors interventions and facilitate comfort, sleep may exaggerate on the
10/10 health teachings, and relaxation pain he experienced
• restlessness the patient will
• VS taken as: verbalizes relief Dependent
T:36.2oC send signal to the brain from pain. >administration of  To relieve pain
RR:28cpm analgesics as prescribed
PR:98bpm
BP: 13O/9OmmHg
perception of pain >application of heat or  Hot moist compress
• shows guarding
cold compress as have penetrating
behavior
ordered
• irritable at times effect. Cold compress
promote some
numbing thereby
promoting comfort
 IX. DRUG STUDY

NAME OF DRUG ORDERED MECHANISM OF ACTION INDICATIONS CONTRAIN- SIDE EFFECTS NURSING
DOSE DICATIONS RESPONSIBILITY

PARACETAMO 5Omg Reduces fever by acting directly • Common cold, flu > Allergy to CNS: headache  Practice the 1O R’s of
L 1tab every 4 on the hypothalamic heat- other viral and acetaminophen CV: chest pain, dyspnea drug administration.
hours regulating center to cause bacterial infections GI: hepatic toxicity and failure
vasodilation and sweating which with pain and fever > use cautiously GU: impotence  Avoid using multiple
helps dissipate heat. with impaired Hematologic: preparations
• Analgesic- hepatic function, methemoglobinemia – containing
antipyretic in chronic cyanosis, hemolytic acetaminophen.
patients with aspirin alcoholism, anemia,.leukopenia, Carefully check any
allergy , hemostatic pregnancy and pancytopenia OTC drugs
disturbances, lactation Hypersensitivity: Rash, fever
bleeding, upper GI  Do not exceed
disease , gouty recommended dose
arthritis
 Take only for
• Arthritis and complaints indicated
rheumatoid for fever. It is not an
disorders involving anti inflammatory
musculoskeletal agent.
pain – but lacks
clinically significant
antirheumatic and
anti-inflammatory
effects.
CELECOXIB 2OOmg Analgesic and anti-inflammatory • Management of >Contraindicated CNS: h/a, tiredness, fatigue,  Practice the 1O R’s of
1capsule BID activities related to inhibition of acute pain with allergies to dizziness, somnolence, drug administration.
the COX-2 enzyme, which is • Treatment of signs sulfonamides, insomnia, tinnitus,
activated in inflammation to cause and symptoms of celecoxib, ophthalmologic effects  Administer drug with
the signs and symptoms rheumatoid arthritis NSAIDsor CV: MI, CVA food or after meals if
associated with inflammation; and osteoarthritis aspirin; Dermatologic: rash, alopecia, GI upset occurs.
does not affect the COX-1 significant renal pruritus, sweating, dry mucous
enzyme, which protects the lining impairment. membranes, stomatitis  Establish safety
of the GIT and has blood clotting GI: dyspepsia, nausea, GI measures if CNS or
and renal functions bleeding, abdominal pain, visual disturbances
>Use cautiously Flatulence occur.
with impaired Hematologic: Neutropenia,
hearing, hepatic leukopenia, pancytopenia,  Take only the
and CV thrombocytopenia prescribed dosage.
conditions
 Report any side
effects.