CUES

Subjective
cues:
- sakit akong
luyo ug wala
nga tiil as
verbalized by
the patient.

Objective
cues:
-received
patient lying
on bed, awake,
coherent, &
responsive.

-IVF of 1 L #
21 PLR with
remaining 270
mL @ 30
gtts/min.
infusing well

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

GOAL &
OUTCOME
CRITERIA

Impaired
physical
mobility,
inability to stand
alone related to
skeletal
impairment to
facture of the left
femoral neck

Fractures occur
when the bone is
subjected to stress
greater that it can
absorb. When the
bone is broken,
adjacent structures
are also affected,
resulting in soft
tissue edema,
hemorrhage into
the muscles and
joints, joints
dislocations,
ruptured ten-dons,
severed nerves, and
damaged blood
vessels. Body
organs maybe
injured by the
force that caused
the fracture
fragments. After a
fracture, the
extremities cannot
function properly

After 8 hours of
rendering appropriate
nursing interventions
the patient will be
able to:

1. Demonstrate
increasing
function of
the
extremities.

NURSING
ACTIONS &
NURSING
ORDERS

RATIONALE

EVALUATION

After 8 hours of
rendering
appropriate
nursing
interventions the
patient was able:

Independent
- assist patient to
do active ROM
exercises on the
lower extremities.

-to improve
muscle
strength and
joint mobility.
(GULANICK
& MYERS:
2007, p. 127)

Dependent

-in order for

the muscle to
-administer
analgesics such as be more relax
Tramadol (Tramal) and relieves
as prescribed by
the pain
the physician.
(GULANICK

1.Demonstrate
increasing function
of the extremities.

2.Regain or
maintain mobility
at the highest
possible level.

3. Verbalize
understanding of
the situation /risk
factors, individual
therapeutic
regimen and

@ right arm.

- grimace face
noted

- limited ROM

because normal
functions of
muscle depend on
the integrity of the
bones which they
are attached.

& MYERS:
2007, p. 127)

-Goal was met

Collaborative
- consult with
physical or
occupational
therapist as
indicated.

(Gulanick &
Myers: 2007, p.
126)

-to develop
individual
exercise or
mobility
program and
identify
appropriate
adjunctive
devices.
(GULANICK
& MYERS:
2007, p. 129)

-v/s

safety.

BP:
130/80
mmHg
T:
38.2C
P : 75
bpm
R : 20
cpm

Independent
2. Regain or
maintain
mobility at
the highest
possible
level.

-assess degree of
mobility produced
by injury or
treatment and note
patients
perception of
immobility.

-patient may
be restricted
by self-view
or selfperception out
of proportion
with actual
physical
limitations
requiring
interventions
to promote
progress
toward

wellness.
(GULANICK
& MYERS:
2007, p. 127)

3. Verbalize
understanding
of the
situation /risk
factors,
individual
therapeutic
regimen and
safety
measures.

NURSING
CUES

Subjective
cues:
- sakit akong
luyo ug wala
nga tiil as
verbalized by
the patient.

Objective
cues:
-received
patient lying
on bed,
awake,
coherent, &
responsive.

- diaphoresis

- pain scale of
8/10, as of 0

SCIENTIFIC BASIS

DIAGNOSIS

Alteration in
comfort : Acute
Pain related to
tissue trauma 2
to MVA

Pain is a typical sensory

experience that may be
described as the
unpleasant awareness of
a noxious stimulus or
bodily harm.
Individuals experience
pain by various daily
hurts and aches, and
occasionally through
more serious injuries or
illnesses. Pain is
defined scientifically as
unpleasant sensory and
emotional experience
associated with actual
or potential tissue
damage, or described in
terms of such damage.
Pain of any type is the
most frequent reason
why people tend to seek
medical consultation. It
is a major symptom in
many medical
conditions, significantly
interfering with a
persons quality of life
and general functioning.
Diagnosis is based on

GOAL &
OUTCOME
CRITERIA

NURSING
ACTIONS &
NURSING
ORDERS

RATIONALE

After 8 hours of
rendering
appropriate nursing
intervention, the
patient will be able
to reduced pain
from 8 to 4 with 10
as the most painful.
1. The patient
will verbalize
reduction of
pain from a
pain scale of 4
in a 0-10 scale
with 10 as the
most painful.

EVALUATION

After 8 hours of
rendering
appropriate
nursing
intervention, the
patient was able
to have reduction
of pain from 8 to
4 with 10 as the
most painful.

Independent
- perform proper
nursing
interventions and
appropriate
procedures to
alleviate pain.
-use nonpharmacologic
interventions for
relieving pain
(eg. Relaxation)

- appropriate
measures will
be
implemented
to prevent
infections and
complications.
- use of nonpharmacologic
methods will
embrace the

1. The patient
will verbalize
reduction of
pain from a
pain scale of
4 in a 0-10
scale with 10
as the most
painful.
2. Patient will
demonstrate
ways to
reduce pain.
3. The patient
will
appreciate the
care rendered.

is no pian and
10 is the most
painful

-guarding
behavior

- T : 38.2C

O occurs
when moving
L on his left
leg
D
approximately
1 min.
C gnawing
pain
A frequent
moving
R rest

characterizing pain in
various ways, according
to duration, intensity,
type (dull, burning or
stabbing), source, or
location in body.
Usually, pain stops
without treatment or
responds to simple
measures such as
resting or taking an
analgesic, and it is then
called acute pain. But it
may become intractable
and develop into a
condition called chronic
pain, in which pain is
no longer considered a
symptom but an illness
by itself. The study of
pain has it recent years
attracted many different
fields such as
pharmacology,
neurobiology, nursing
sciences, dentistry,
physiotherapy, and
psychology. Pain
medicine is a separate
subspecialty figuring
under some medical
specialties like
anesthesiology,
physiatry, neurology,
and psychiatry. Pain is
part of the bodys
defense system,
triggering a reflex
reaction to retract from

results of pain - Goal was met

reliever. Gate
control theory
states that
cutaneous
stimulation
closes the pain
pathways.
(BARE &
SMELTZER,
2004: 1140)
-in order for
the muscle to
be more relax
and relieves
the pain
Dependent

(GULANICK
& MYERS:
--administer
analgesics such as 2007, p. 127)
Tramadol
(Tramal) as
prescribed by the
physician.

2. Patient will
demonstrate
ways to reduce

Independent
- instruct patient
to use relaxation
exercises such as
focused

-diverts
attention and
may enhance
coping
abilities.
(DOENGES,
2002:368)

T Tramadol
(Tramal)

a painful stimulus, and

helps adjust behavior to
increase avoidance of
that particular harmful
stimulation in the
future. Given its
significance, physical
pain is also linked to
various cultural,
religious, philosophical,
or social issues.
(http://en.wikipedia.org)

pain.

breathing,
commercial or
individualized
tapes.
Dependent
-provide
individualized
physical therapy
or exercise
program that can
be continued by
the client when
discharged.
Collaborative
-encourage
patient to have
adequate bed rest
periods.

-promotes
active, not
passive role.
(DOENGES,
2002: 369)

-bed rests
decreases
body
metabolism
and thus
reduces
muscle
tension.
(BARE &
SMELTZER,
2004: 1140)

- Establish a
trusting
relationship
that
encompasses
Independent
patients
-establish a
physiological,
specific time to
emotional,
talk with patient
about pain and its social, sexual,
psychological and and financial
emotional effects. concerns.
(SPARKS &
TAYLOR,
2005: 227)

- Pain is a
subjective
experience
and cannot be
felt by others.
(DOENGES,
2002: 367)

Dependent
-accept clients
description of
pain.
3. The patient
will appreciate
the care
rendered.

- to achieve
pain
management
goals and
maximize
patients
cooperation.
(SPARKS &
TAYLOR,
2005: 227)

Collaborative
-work closely
with staff and
patients family.

NURSING
CUES

Subjective

DIAGNOSIS

SCIENTIFIC BASIS

GOAL &
OUTCOME
CRITERIA

NURSING
ACTIONS &
NURSING
ORDERS

RATIONALE

EVALUATION

cues:
-lisod man
ilihok akong
lawas as
verbalized by
the patient.