ASSESSMENT NURSING PLANNIN OUTCOME INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS G IDENTIFICA
TION

Subjective: Acute pain r/t After 1hr. The patient  Obtain patient’s  To obtain 1. Goals are
“Musakit og fracture and of nursing will be able assessment of subjective data partially
ayo ang ako muscle spasm interventi to: pain to include about the pain met?
bat-ang pag ons, the 1. Verbalize location, that the patient 2. The patient
mulihok ko”, patient decrease characteristics, feels, and rule was able to
as verbalize by SCIENTIFIC will or and out underlying verbalize
the patient. BASIS: verbalize absence of intensity/quality, condition/ decrease
Pain absence pain; from frequency, and development of pain
scale:10/10 Osteoporosis or pain scale aggrevating complications sensation
is a disease of controlled of 10/10 factors; use pain when taking
Objective: bones that pain. to 0/10. scale of 0-10. medications?
 Pain in the leads to an 2. Verbalize  These are 3. The patient
hip bone increased risk understan  Monitor skin color usually altered was able to
 Cant’t sit of fracture. dings and v/s. in acute pain; to demonstrate
and stand Osteoporotic about the obtain baseline nonpharmac
without fractures are importanc data ologic
assistance those that e of both  Provide comfort techniques
 Altered ADL occur in pharmacol measures such as  To decrease with
 Facial situations ogic and back rubs, use of pain sensation assistance of
grimace where healthy non- heat/cold packs through S.O?
noted people would pharmacol to the affected nonpharmacolo
 Guarding not normally ogic area. gic approach.
behavior break a bone; therapies
noted they are to  Encourage
 Pain upon therefore decrease patient to have  To provide
moving regarded as pain. bed rest; provide comfort and
 Roentgenol fragility 3. Demonstr a comfortable decrease pain
ogic report: fractures. ate linens and a firm
lumbosacra Typical relaxation and non-sagging
l APL fragility technique mattress
fractures occur s and
 Moaning
 noted in the divertional  Encourage  To distract
 Spinal vertebral activities patient to attention from
disproporti column, rib, to perform relaxing pain and reduce
on at the hip and wrist. decrease activities/exercise tension.
lumbar The symptoms pain. (deep breathing
spine of a vertebral exercises)
collapse  To minimize
("compression  Advice patient back pain and
O- when fracture") are (and assist prevent further
performing sudden back patient in turning injury of the
weight-bearing pain, often sides) to move affected back.
exercises with the trunk as a
radiculopathic unit and avoid
L-lower back pain (shooting twisting.  To immobilize
(lumbar area) pain due to and support the
nerve root  Encourage lumbar area
D-5 minutes compression) patient to apply when moving.
after initiation and rarely with lumbosacral
of movement spinal cord corset/binder  Calcium,
compression phosphorus and
C-10/10 or cauda  Encourage vit. D are
equina patient to take essential for
A- when syndrome. adequate balance bone formation,
sitting/ Multiple diet, rich in increase bone
standing vertebral calcium, density and
fractures lead phosphorus and mass
R- lower to a stooped vit. D. (e.g. milk,
extrimities posture, loss salmon, sardines,
of height, and egg, liver)  To prevent
T- Tenoxicam chronic pain patient from
20mg 1 tab with resultant  Assist patient to having pressure
OD reduction in
turn to sides ulcers.
mobility.
Calcium every 2hrs.
carbonate (source:
1 tab OD Dependent:  To aide faster
http://en.wikip
Ketorolac edia.org/wiki/O  Provide healing.
30mg IVTT steoporosis) medication
therapies as
prescribed by the
physician such as
the ff.:
Tenoxicam
20mg 1 tab OD
Calcium
carbonate
1 tab OD
Ketorolac 30mg
IVTT

ASSESSMENT NURSING PLANNIN OUTCOME INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS G IDENTIFICA
TION

Subjective: Impaired Within The patient  Assess degree of  To determine 1. Goals

“Musakit og physical 8hrs. of will be able pain in intensity of pain partially
ayo ang ako mobility r/t nursing to: accordance to perceived by met?
bat-ang pag pain and interventi 1) Participate patient’s the patient and 2. The patient
mulihok ko”, discomfort of ons, the ADLs and description. his/her was able to
as verbalize by the lumbar patient desired tolerance perform
the patient. area. will be activities. towards pain. activities
able to 2) Demonstr with
Objective: SCIENTIFIC regain ate assistance
 Determine degree  To assess
 Pain in the BASIS: mobility willingnes of immobility in functional and when
hip bone Osteoporosis without s to relation to ability. there is
 Cant’t sit is a disease of hesitance participate assessment for absence of
and stand bones that . in pain. pain?
without leads to an interventio  Feelings of 3. The patient
assistance increased risk ns that will  Note emotional/ frustration/powe was able to
 Altered ADL of fracture. help her behavioral rlessness may verbalize
 Facial Osteoporotic improve response to impede decrease
grimace fractures are mobility problem of attainment of pain
noted those that 3) Verbalize immobility goals sensation
 Guarding occur in decrease when taking
behavior situations or  To promote medications?
noted where healthy absence of  Provide comfort nonpharmacolo 4. The patient
 Pain upon people would back pain measures such as gic relief of was able to
moving not normally upon use of heat/ cold pain. demonstrate
 Roentgenol break a bone; moving. packs to the nonpharmac
ogic report: they are 4) Verbalize affected body ologic
lumbosacra therefore understan part.  To minimize techniques
l APL regarded as dings back pain and with
fragility about the  Advice patient prevent further assistance of
 Moaning
fractures. importanc (and assist injury of the S.O?
noted
Typical e of both patient in turning back 5. The patient
 Spinal
fragility pharmacol sides) to move was free
disproporti
fractures occur ogic and the trunk as a from any
on at the
in the non- unit and avoid signs of
lumbar
vertebral pharmacol twisting.  To distract pressure
spine
column, rib, ogic attention from ulcers; and
 Altered hip and wrist. therapies free from
mobility  Encourage pain and reduce
The symptoms to patient to tension further
of a vertebral decrease perform relaxing injury?
collapse pain. activities/exercise
("compression 5) Maintain (deep breathing
fracture") are skin exercises)
sudden back integrity  To support
pain, often as lumbar area
with evidence when moving
radiculopathic by  Encourage
pain (shooting absence of patient to apply
pain due to pressure lumbosacral  To prevent
nerve root ulcer corset or binder. pressure ulcers
compression) 6) Be free
and rarely with from any
 Assist patient to  To keep body
spinal cord injury.
turn to sides
compression every 2hrs. well hydrated
or cauda and to decrease
equina  Encourage risk for
syndrome. increase fluid constipation
Multiple intake 2000-
vertebral 3000ml/day
fractures lead within cardiac  To aide faster
to a stooped tolerance. healing.
posture, loss
of height, and Dependent:
chronic pain
with resultant  Provide
reduction in medication
mobility. therapies as
prescribed by the
(source: physician such as
http://en.wikip the ff.:
edia.org/wiki/O Tenoxicam
steoporosis) 20mg 1 tab OD
Calcium
carbonate
1 tab OD
Ketorolac 30mg
IVTT
ASSESSMENT NURSING PLANNIN OUTCOME INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS G IDENTIFICAT
ION

Subjective: Risk for After 8hrs. The patient  Maintain bed  Provides 1. Goals are
injury: of nursing will be able rest as indicated. stability, partially
“ dili ko met?
fracture r/t interventio to: Provide support reducing
makatindog og when possibility of 2. Patient does
effects of ns the
makalingkod 1. Report moving/turning. disturbing not manifest
change in patient will any signs of
kay musakit increase alignment/muscl
bone maintain e spasms, which further
ang ako bat- comfort,
structure absence of decrease enhances fractural
ang.” As
secondary to additional pain.  Advise the healing. injury?
verbalized by
osteoporosis. fracture. 2. Verbalize patient to sleep 3. The patient
the patient. was able to
importance on a soft  Excessive bed
SCIENTIFIC of health mattress and to verbalize
rest may cause decrease
BASIS: teachings avoid excessive further
imparted to bed rest. pain
Objective: complications
Osteoporosis prevent sensation
such as pressure when taking
 Spinal is a disease of additional ulcers,
injury. medications
disproportio bones that constipation and
3. Report ?
n at the leads to an contractures.
absence of 4. The patient
lumbar increased risk Firm mattress
complicatio was able to
spine. of fracture. may increase
ns due to maintain
 Pain at the  Advice patient to patient’s intact skin
Osteoporotic lack of
hip bone apply comfort. integrity?
fractures are mobility. lumbosacral
 Can’t stand those that corset/binder .
and sit occur in  To immobilize
 Altered situations  Advice patient and support the
mobility where healthy (and assist lumbar area
 Altered ADL patient in turning when moving.
people would
 Roentgenol sides) to move
not normally the trunk as a
ogic report:  To minimize
break a bone; unit and avoid back pain and
lumbosacral
APL they are twisting. prevent further
therefore injury of the
regarded as affected back.
fragility  If the patient
takes a calcium
fractures.
supplement,
Typical encourage liberal  To help maintain
fragility fluid intake adequate urine
fractures output and
occur in the thereby avoid
vertebral  Tell the patient renal calculi,
column, rib, to report new hypercalcemia,
pain sites and
hip and wrist.
immediately, hypercalciuria.
The especially after
symptoms of trauma.  To prevent
a vertebral patient from
collapse  Assist patient to having pressure
("compressio turn to sides ulcers.
n fracture") every 2hrs.
are sudden
 Encourage the
back pain,
patient to install  To prevent
often with safety devices, pressure ulcers
radiculopathic such as grab
pain (shooting bars and railings,  To prevent
pain due to at home. additional injury
 nerve root  Advice patient to when at home.
compression) use support
and rarely canes/walking
with spinal cane when
walking or  To balance
cord
standing. patient and
compression
pevent
or cauda  Encourage additional injury.
equina patient to take
syndrome. adequate
balance diet, rich  Calcium,
Multiple
in calcium, phosphorus and
vertebral phosphorus and vit. D are
fractures lead vit. D. (e.g. milk, essential for
to a stooped salmon, bone formation,
posture, loss sardines, egg, increase bone
of height, and liver) density and
chronic pain mass
with resultant
reduction in
mobility.

(source:
http://en.wiki
pedia.org/wiki
/Osteoporosis
)

ASSESSME NURSING PLANNIN OUTCOME INTERVENTIONS RATIONALE EVALUATION

NT DIAGNOSIS G IDENTIFICAT
ION

Subjective: Self-care Within 8 The patient  Tell the These are usually 1. Goals are
 “Dili nako deficit: hrs. of will be able patient to report altered in acute partially
makagam sa Bathing and nursing to: new pain site pain; to obtain met?
ako toileting r/t interventio 1. Perfor immediately, baseline data 2. The patient
kaugalingon pain & ns, the m self – especially after was able to
“as discomfort patient will care trauma. verbalize
verbalize by upon moving. experience activities  To decrease pain decrease
the patient. increase within  Advise to sensation and to pain
SCIENTIFIC comfort & level of stay on a non- provide comfort. sensation
BASIS: decrease own sagging and firm when she
Objective: pain. ability. mattress and feels
 Pain at Patient may be 2. Expres avoid excess bed  Increases comfortable
the hip immobilized s positive rest. comfort by ?
bone by pain, feelings relaxing back 3. The patient
 Can’t muscle about her.  Encourage muscles. able to
stand and weakness or the patient to express
sit they may be perform knee  Moving the trunk feelings
without immobilized flexion. as a unit helps without
assistanc for therapeutic the pain lesser hesitant?
e reasons. When  Encourage and twisting can
 Altered mobility is the patient to promote pain
mobility impaired, the move the trunk sensation.
 Altered well-known & avoid twisting.
ADL consequences  Promote muscle
may include relaxation.
 Roentgen
activity  Apply
ologic
intolerance, intermittent local
report:  To prevent back
loss of muscle heat and back
lumbosac pain & promote
mass, strength rubs.
ral APL good posture.
and self-care
 Pain upon
deficit.
moving  Encourage
 Guarding good posture  To promote
Linton, A. et al,
behavior and teach proper positive sense of
(2007)
body mechanics self & distract
Matteson and
attention from
McConnell’s
 Encourage pain and reduce
Gerontological
Nursing use of tension.
Concepts and visualization,
Practice 3 guided imagery,
rd & relaxation.
ed. Pp. 284-
285  Enhances
coordination &
continuity of
care.
 Provide for
communication
among those
who are involved
in caring Instruct
the S.O. to
provide privacy
and equipment
of the patient
within easy
reach during
personal care  To minimize
activities for the back pain and
patient. prevent further
injury of the
Dependent: affected back.

 Provide
medication
therapies as .
prescribed by
the physician
such as the ff.:
Tenoxicam
20mg 1 tab OD
Calcium
 carbonate
1 tab OD
Ketorolac 30mg
IVTT

ASSESSME NURSING PLANNIN OUTCOME INTERVENTIONS RATIONALE EVALUATION

NT DIAGNOSIS G IDENTIFICAT
ION

Subjective: Disturbed self- Within 8 The patient  Develop  Promotes 1. Goals are
“Wala na esteem r/t loss hrs. of will be able therapeutic trusting partially
jud koy of health nursing to: relationship: situation in met?
gamit kay status & interventio 1. Participate which patient is 2. The patient
• Provide
dili na ako independent ns, the in activities in free to be open was able to
encourage
makalihok functioning. patient will a real life and honest with verbalize
ment for
ug ako ra verbalize situation to self. positive
efforts.
usa” as increase enhance outlook in
• Maintain
verbalize by SCIENTIFIC sense of change. current
open
the patient.. BASIS: self worth situation?
communica
in relation 2.  Addressing 3. The patient
 Losing one’s to current Demonstrate tion. issues openly was able to
Objective: dependent situation. behavior provides accept her
 Perceived function changes to  Talk to opportunity for condition?
herself as makes the restore patient with change.
unhealthy patient feels positive self positive outlook
(scale:1/1 disable that image. in life.  Can develop an
0) could probably internal locus of
 Pain upon affect her/his control by
moving self worth.  Advise to recognizing
 Can’t When a recall her past these aspects of
stand and patient is successes & them.
sit experiencing strengths.
without loss of health  Positive word
assistanc status he/she encouragement
e. may feels also s promote
 Altered losing one’s  Give continuation of
mobility hope and faith. reinforcement efforts
 Altered for progress supporting
ADL noted. development of
Source: coping
 Roentgen
www.google.c behaviors.
ologic
om
report:
lumbosac  Facilitates
ral APL comfortable
 Guarding  Encourage feelings.
behavior expression of
feelings &
anxieties.  Enhances sense
of well-being &
can help
 Encourage energize
the patient to patient.
involve in
exercise  To promote
program & sense of self.
promote
 socialization.
 To make her
 Encourage feel better when
use of they present a
visualization, positive outer
guided imagery, appearance.
& relaxation.
 Increases
 Emphasize likelihood they
importance of will provide
grooming & appropriate
personal support to
hygiene. patient.

 Helps patient
 Involve the identify 8 cope
S.O. in teaching with the
to manage underlying
current situation. reason for
dependency.

 Assisting both
the patient &
support people
to recognize
continued
dependency.