VI.

NURSING CARE PLAN

NURSING DIAGNOSIS

ACUTE PAIN related to tissue trauma as manifested by guarding behavior, grimacing face and a verbalization of Nasakit latta a anakko.

NURSING INFERENCE

Pain is a subjective unpleasant sensation resulting from stimulation of sensory nerve endings by injury or other harmful factors. Pain is activated when a patients pain threshold is reached. Since the patient underwent operation due to fracture, this activated the pain receptors to produce a feeling of pain.

NURSING GOAL

After 3-5 days of rendering appropriate nursing interventions, the client will be able to demonstrate use of relaxation skills and diversional activities as indicated and report pain is relieved.

NURSING INTERVENTIONS 1. Obtain clients assessment of pain to include location, characteristics, on-set, duration, frequency, quality, intensity and aggravating factors. Note and investigate changes from previous reports.

To establish baseline for assessing improvement.

 To rule out worsening of underlying condition/development of complication.

2. Note when pain occurs.

To medicate prophylactically, as appropriate.

3. Provide comfort measures such as repositioning, quiet environment and calm activities.

To promote nonpharmacological pain management.

4. Encourage use of relaxation techniques such as focused breathing, listening to music.

To distract attention and reduce tension.

5. Administer analgesics, as indicated, to maximum dosage, as needed. Notify physician if regimen is inadequate to meet pain control goal. To maintain acceptable level of pain.

6. Encourage adequate rest periods.

To prevent fatigue.

NURSING EVALUATION

After 3-5 days of rendering appropriate nursing interventions, the client was able to demonstrate use of relaxation skills and diversional activities as indicated and report pain is relieved.

NURSING DIAGNOSIS

IMPAIRED PHYSICAL MOBILITY related to musculoskeletal impairment as manifested by imposed restrictions, reluctance to attempt movement and limited range of motion.

NURSING INFERENCE

Due to the fractured arm of the patient, he cannot perform some activities of daily living such as basic self-care thus there is impaired physical mobility.

NURSING GOAL

After 3-4 hours of rendering appropriate nursing interventions the patient will be able to verbalize understanding of situation and individual treatment regimen and safety measures and demonstrate techniques/behaviors that enable resumption of activities.

NURSING INTERVENTIONS 1. Assess degree of pain, listening to clients description.

To establish baseline for assessing improvement.

2. Observe movement when patient is unaware of observation.

To note any incongruencies with reports of abilities.

3. Encourage participation in self-care, occupational/diversional/recreational activities.

 To enhance patients self-concept and sense of independence.

4. Schedule activities with adequate rest periods during the day.

To reduce fatigue

5. Encourage intake of adequate fluids/nutritious foods.

To promote well-being and maximize energy production.

NURSING EVALUATION

After 3-4 hours of rendering appropriate nursing interventions the patient was able to verbalize understanding of situation and individual treatment regimen and safety measures and demonstrate techniques/behaviors that enable resumption of activities.

NURSING DIAGNOSIS

RISK FOR INFECTION related to musculoskeletal impairment.

NURSING INFERENCE

Risk for infection occurs when a person is at risk for being invaded by pathogenic organisms. Transmission of an infectious agent from a source to a susceptible host occurs within an environment. Organisms live and multiply in a reservoir. The reservoir provides what the organisms needs for survival at a specific stage in its life cycle. In the patients case, the dressing and the broken skin can be the reservoir that may lead to infection.

NURSING GOAL

After 2-3 days of rendering appropriate nursing interventions, the patient will be able to identify procedures to prevent/reduce risk of infection and demonstrate techniques, lifestyle changes to promote safe environment.

NURSING INTERVENTIONS

1. Instruct patient/caregiver to wash hands before contact with postoperative patient. Teach use of aseptic technique during wound care.

To reduce risk factors.

2. Assess incisions for redness, drainage, swelling and increased pain.

To assess causative/contributing factors.

3. Administer prophylactic antibiotics as indicated.

To reduce risk factors.

4. Emphasize necessity of taking antivirals/antibiotics as directed.

Premature discontinuation of treatment when patient begins to feel well may result in return of infection and potentiate drug-resistant strains. 5. Discuss importance of not taking leftover drugs unless specifically instructed by healthcare provider.

Inappropriate use can lead to development of drug-resistant strains/secondary infections.

NURSING EVALUATION

After 2-3 days of rendering appropriate nursing interventions, the patient was able to identify procedures to prevent/reduce risk of infection and demonstrate techniques, lifestyle changes to promote safe environment.