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I. Patients DataA. General DataName: Patient PalabiroAddress: Dura, Tarlac City
Age: 26
Sex: Male
Birth Date: December 13, 1983
Religion: Roman Catholic
Nationality: Filipino
Civil status: Single
Rank in the family: 4th
son
Date of Admission: July 31, 2010Order of Admission: emergency repair on his right leg
Attending Physician: Dr. Relem Jessie
B. Chief complaint:Sudden pain in the right extremities of the patient due to the trauma from a motor cycle accident
C. Presence illness status:Presence of fracture on right leg to tibia up to fibula
D. Past Health Status:Childhood illness fever and chicken pox
Immunization only once, BCG on his first shotMajor illness None
Allergy None
E. Family AssessmentMember Relation Age Sex Occupation Educational
Attainment
1st
son
2nd
son
3rd
son
5th daughter
6th
son
Mother
Father
Brother
Brother
Brother
Sister
Brother
Mother
Father
36
34
32
24
22
53
60
Male
Male
Male
Female
Male
Female
Male
Construction
None
None
None
None
Housewife
Farmer
High school
High school
High school
High school
High school
Elementary
High school
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F. System Review1. Health Perception Pattern:
Pt. Perception about Health: ang buhay parela-relax langPt. Perception about illness: Buwisit yan sa Buhay
Pt. Perception about Health maintenance and habit: Basta Walang problema, ayos
Compliance w/ prescribe Medication: No Reaction
2. Nutritional Metabolic Pattern:Food: mostly Leafy Vegetable and rarely on fish and meat
Water: pt. consumed 10 glasses of water every day
Beverage: Mostly, the Pt. consumes Liquor and beer
3. Elimination patternBowel:Habits: plain naked during defecation
Odor: Aromatic
Consistency: Thick
Laxative use: none
Bladder:
Color: Dark orange
Odor: Aromatic
Alteration: none
4. Activity Exercise Pattern:Feeding - 0 Dressing - II Grooming II
Bathing - II Toileting - II Cooking - IV
Bed mobility - II Home Maintenance - III Other - 0
Legend:
0 Full careI Need for Equipment
II Need for Assistance
III Both
IV Dependent
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5. Cognitive perceptual pattern:Hearing: no use of equipment
Vision: no use of equipment
Sensory perceptual: to his opinion its okay
Learning style: responsive but no reaction about the topic
6. Sleeping rest pattern:Special sleeping problem: None
Hours of sleep: in day, he sleeps in 3 hours but in night he sleeps 11 hours
Alteration: none
Sleeping aids: none
7. Self Perception pattern:Felling about his current health status: kawawa naman akoDescription about his self: palabiro
Capabilities and weakness: malakas ako sa lahat pero hindi sa babae
Decription about Self Worth: sobrang halaga ko sa sarili ko noh
8. Role Relation pattern:Description about his role in the family: Wala nakahiga lang ako
Description about his role in the Work: no answer due to him has any any work at all
Description about his role in the Social Community: wala tambay lang ako
9. Sexual Reproduction PatternContraceptive: noneSexual Activity: none
Reproductive Problem: none
History of sex abuse: none
10. Coping stress tolerance Pattern:Perception about Stress: Pt. has no idea of stress because on his state that he only serve as a tambay
Coping Activities During Stress: none
11. Value Belief Pattern:Value Belief: none, the patient belief only him self
Religion and spiritual Belief: none because pt. is rarely go to church and belief about the bibleG. Herodo-familial Illness
Paternal illness: none
Maternal illness: none
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H. Developmental History:Theorist Age of the pt. Sex Pt. description
Erickson On the grade 1 day as he stated Male nung bata ako hnd ako halos takotsa tatay ko,alam mu n medyo
matapang na ako noon
Freud 11 years old Male Medyo pinagpa2ntasiyaan ko
noon mga klasse ko nun
Piaget 15 years old Male bad boy ako noon,sakit nga daw
kami ng ulo
Kohlberg 15 years old Male wala akong masyadong ginagawa
noon na matino eh
fowler On his present age Male Hay tanda kong to medyo hindi
na ako naniniwala kung minsan
II. Physical Assessment1. General Survey:Pt. is on bed with a presence of dressing on his right leg with an positive mood but no proper gaits and posture
Vital Signs:
Bp: mmhg
PR: Cpm
RR: Bpm
T: C
2. Head, hair and face:Pt. has a normocephalic and in round shape with a presence of hematoma on the right eye and papule on the fore head3. Eyes:Pt. eye has a normal vision, with no vision aid required and also pupil reacted on light but there is a presence of hematoma on the peri-orbital of
his right eye
4. NosePt. nose is symmetrical and no anomalies and masses, no discharge and also the color is paired to the skin color
5. EarsPt. ears is symmetrical and a lined with each other, no presence of discharge and masses
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6. Mouth and throatPt. mouth is symmetrical with an occurrence of burses in the upper lip and has a dark scaly lips, tenderness occur on the lips but not on the inner
mouth and throat
7. Neck and lymph nodes:Pt. neck is symmetrical and with tenderness of the lymph nodes
8. Skin and mucus membranePt. skin is in color dark brown with a masses on the forehead and a presence of hematoma on the right peri-orbital with dry mucosa on the lips
and eyes and most fully dry skin
9. NailsPt. nail is in fleshy color appropriate to the mucus membrane with a normal capillary refill and no abnormalities
10. Thorax and lungs:Pt. has a normal RR and no presence of abnormal sound in the lung and the chest wall is in normal range of 2:111. Cardio-VascularPt. has a normal rate with no anomalies but presence of barchycardia
12. Breast and axillaPt. breast is symmetrical and no masses has been palpated
13. AbdomenPt. abdomen is flat and round and presence of burborigmus found and no other abnormal sound detected
14. Extremities:Pt. Extremities is all normal except on his right lower leg due to the fracture
15. Neuro-carnial nervesAll nerves are functioning well16. Rectal and analNot asses
17. GenitalNot asses
III. Personal and Social History:a. Habit and vices: sleeping mostlyb. Caffeine: 1 cup per dayc. Smoke: 1 pack per dayd. Alcohol: 5 bottle per drinking sessione. Drugs: nonef. Lifestyle: always relax and inactiveg. Social affiliation: drinking session and palanith. Rank in the Family: 4th soni. Educational attainment: high school graduate
IV. Environmental healthhistory:Pt. stated that in there community there are always fight seen and prone to chismosa area
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V. Introduction of the diseaseBone fracture
yIs a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impact or stress,or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis
imperfecta, where the fracture is then termed pathological fracture.
Types:
Closed (simple) fractures
Are those in which the skin is intact.
Open (compound) fractures
Involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may
thus expose bone to contamination.Other types:
Complete fracture: A fracture in which bone fragments separate completely.
Incomplete fracture: A fracture in which the bone fragments are still partially joined.
Linear fracture: A fracture that is parallel to the bone's long axis.
Transverse fracture: A fracture that is at a right angle to the bone's long axis.
Oblique fracture: A fracture that is diagonal to a bone's long axis.
Spiral fracture: A fracture where at least one part of the bone has been twisted.
Comminuted fracture: A fracture in which the bone has broken into a number of pieces.
Compacted fracture: A fracture caused when bone fragments are driven into each other.
Signs and Symptoms
Local pain
Local bleeding
Local swelling
Deformity or dislocation
Symptoms of associated nerve damage: Numbness; Paralysis
Loss of pulse below fracture
Complication
y Bleedingy Hemorrhagey Shocky Deathy Circulatory problems
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y EmbolismDiagnostic test and treatment
y Physical examinationy X-raysy Computed tomography scanPain management
Ibuprofen has been found to be equally effective as the combination of acetaminophen and codeine.
Immobilization
Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best possiblefunction of the injuredpart after healing.
Surgical procedure
Bone grafting
-repairing of the damage bone
Electrical bone growth stimulation or osteostimulation
-Has been attempted to speed or improve bone healing.
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VI. Anatomy PhysiologyFibula
y Although this bone runs parallel to the Tibia, it doesnt actually carry much weight. Instead, it acts as a stabilizer. It articulates with the Tibiaand the Talus. Its inferior end (Lateral Malleolus) is the bone that sticks out on the outside of the ankle. The Fibula can be found on the
lateral side (outside) of the lower leg.
Tibia
y The Tibia articulates with the Femur (upper leg) and the Talus (Ankle). This bone carries all the bodys weight. It is the main bone of the lowerleg and can be found on the more medial side of the leg.
Lower leg fractures include fractures of the tibia and fibula. Of these two bones, the tibia is the only weightbearing bone. Fractures of the
tibia generally are associated with fibula fracture, because the force is transmitted along the interosseous membrane to the fibula.The skin and subcutaneous tissue are very thin over the anterior and medial tibia and as a result of this, a significant number of fractures to
the lower leg are open. Even in closed fractures, the thin, soft tissue can become compromised. In contrast, the fibula is well covered by soft
tissue over most of its course with the exception of the lateral malleolus.
The tibia and fibula articulate at the proximal tibia-fibular syndesmosis.
Fractures of the tibia can involve the tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft, and tibial plafond.
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This are the common fracture in tibia associated with the fracture of the fibula:
Tibial plateau fractures. Line drawings of Schatzker types I, II, and III tibial plateau fractures. Type I consists of a wedge fracture of the lateral
tibial plateau, produced by low-force injuries. Type II combines the wedge fracture of the lateral plateau with depression of the lateralplateau. Type III fractures are classified as those with depression of the lateral plateau but no associated wedge fracture.
Tibial plateau fractures. Line drawings of Schatzker types IV, V,
and VI tibial plateau fractures. Type IV is similar to type I fracture, except that it involves the medial tibial plateau as opposed to the lateral
plateau. Greater force is required to produce this type of injury. Type V fractures are termed bicondylar and demonstrate wedge fractures of
both the medial and lateral tibial plateaus. Finally, type VI fractures consist of a type V fracture along with a fracture of the underlying
diaphysis and/or metaphysis.
Reference:
y Lippincott William and willcot medical-surgical booky Nursingcrib.comy eMedicine.comy WrongDiagnosis.comy Google.com.ph
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VII. Pathophysiology
Motorcycle accident occur
Sudden impact traumatize the right leg of the patient
Trauma, break down the skeletal cells on the right tibia and fibula and also cut the skin of the patient
Break down May causes cracking and breaking of the tibia and fibula
Disposition bone, fragment and point edge of the cracked or break tibia and fibula, causes injury to the arteries and nerves
Sudden accumulation of blood in the fractured site that may causes enlargement on the traumatize leg
Signs and Symptom
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VIII. Laboratory and Diagnostic ResultHematology Result
Date: August 01, 2010
Patient: ----------------
Physician: Mendoza
Test Result Reference Range
WBC: 15.4 G/L
LYM: 2.3 R2 14.7 % L
*MID: 0.6 3.9 % M
GRAN: 12.5 81.4 % G
4.1 10.9 G/L
0.6 4.1 10.0 58.5 % L
0.0 1.8 0.1 24.0 % M
2.0 7.8 37.0 92.0 % G
RBC: 4.77 T/L
HCB: 103. g/L
HCT: .327 L/L
MCV: 68.5 fL
MCH: 21.6 PG
MCHC: 315. g/L
4.20 6.30 T/L
1.20- 180. g/L
.370 - .510 L/L
80.0 97.0 fL
26.0 32.0 PG
310. 360. g/L
PLT: 189. G/L 140 440 G/L
Significance:
Based on the result, the increase of WBC and GRAN indicates about a invasion of Microorganism; this is a way of our body to defend it self from
microbes, in the other hand the sudden decrease of HCB, HCT, MCV, and MCH is indicating an episode of bleeding, this factor factors are affectedduring blood lost.
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IX. Drug StudyGeneric name: Ketorolac
Brand Name: Ketorolac
Drug Classification: analgesic, anti-inflammatory and anti-Pyretic
Dosage: 2 ml per IV push
Indication: post-op pain and hyperthermia
Mechanism of action Side effect and Adverse
Reaction
Contraindication Nursing Consideration
- Inhibits prostaglandin
synthesis, producing
peripherally mediatedanalgesia
- Also has antipyretic and
anti-inflammatory
properties.
- CNS:
1) drowsiness
2) abnormal thinking3) dizziness
4) euphoria
5) headache-
- RESP:
1) asthma
2) dyspnea
- CV:
1) edema
2) pallor3) vasodilation
- GI:
1) GI Bleeding
2) abnormal taste
3) diarrhea
4) dry mouth
5) dyspepsia
6) GI pain
7) nausea- GU:
1) oliguria
2) renal toxicity
3) urinary frequency
- DERM:
1) pruritis
2) purpura
3) sweating
- Hypersensitivity
- Cross-sensitivity with
other NSAIDs mayexistPre- or perioperative
use
- Known alcohol
intoleranceUse cautiously
in:
1) History of GI bleeding
2) Renal impair-ment
(dosage reduction may be
required)3) Cardiovascular disease
- Patients who have asthma, aspirin-induced allergy, and nasal polyps
are at increased risk for developing hypersensitivity reactions. Assess
for rhinitis, asthma, and urticaria.- Assess pain (note type, location, and intensity) prior to and 1-2 hr
following administration.
- Ketorolac therapy should always be given initially by the IM or IV
route. Oral therapy should be used only as a continuation of
parenteral therapy.
- Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs,
acetaminophen, or other OTC medications without consulting health
care professional.
- Advise patient to consult if rash, itching, visual disturbances, tinnitus,weight gain, edema, black stools, persistent headche, or influenza-like
syndromes (chills,fever,muscles aches, pain) occur.
- Effectiveness of therapy can be demonstrated by decrease in
severity of pain. Patients who do not respond to one NSAIDs may
respond to another.
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4) urticaria
- HEMAT:
1) prolonged bleeding
time
- LOCAL:
1) injection site pain
- NEURO:
1) paresthesia
- MISC:
1) allergic reaction,
anaphylaxis
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Generic name: Cefuroxime Sodium
Brand Name: Cefuroxime
Drug Classification: anti-infective; antibiotic; second-generation cephalosporin
Dosage: 5 ml every one IV Push
Indication: for the other cephalosporins, although as a second-generation it is less susceptible to Beta-lactamase and so may have greater activity
against Haemophilus influenzae, Neisseria gonorrhoeae and Lyme disease.
Mechanism of action Side effect and Adverse
Reaction
Contraindication Nursing Consideration
Inhibit any microorganism
during invasion
Diarrhea, nausea,
vomiting,
headaches/migraines,
dizziness and abdominalpain.
Hypersensitivity to
cephalosporins.
y Determine history of hypersensitivity reactions tocephalosporins, penicillins, and history of
allergies, particularly to drugs, before therapy is
initiated.y Lab tests: Perform culture and sensitivity tests
before initiation of therapy and periodically
during therapy if indicated. Therapy may be
instituted pending test results. Monitor
periodically BUN and creatinine clearance.
y Inspect IM and IV injection sites frequently forsigns of phlebitis.
y Report onset of loose stools or diarrhea.Although pseudomembranous colitis (see Signs &Symptoms, Appendix F) rarely occurs, this
potentially life-threatening complication should
be ruled out as the cause of diarrhea during and
after antibiotic therapy.
y Monitor for manifestations of hypersensitivity(see Appendix F). Discontinue drug and report
their appearance promptly.
y Monitor I&O rates and pattern: Especiallyimportant in severely ill patients receiving highdoses. Report any significant changes.
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Generic name:ranitidine hydrochloride
Brand Name: Ranitidine
Drug Classification: GASTROINTESTINAL AGENT; ANTISECRETORY (H2-RECEPTOR ANTAGONIST)
Dosage:
Indication: Short-term treatment of active duodenal ulcer. Most patients heal within 4 weeks. Studies available to date have not assessed the
safety of Ranitidine in uncomplicated duodenal ulcer for periods of more than 8 weeks.
Mechanism of action Side effect and Adverse
Reaction
Contraindication Nursing Consideration
Potent anti-ulcer drug that
competitively and
reversibly inhibits
histamine action at H2-receptor sites on parietal
cells, thus blocking gastric
acid secretion. Indirectly
reduces pepsin secretion
but appears to have
minimal effect on fasting
and postprandial serum
gastrin concentrations or
secretion of gastricintrinsic factor or mucus
None y Symptomaticresponse to therapy
with Ranitidine does
not preclude thepresence of gastric
malignancy.
y Since Ranitidine isexcreted primarily by
the kidney, dosage
should be adjusted in
patients with
impaired renal
functiony Rare reports suggest
that Ranitidine may
precipitate acute
porphyric attacks in
patients with acute
porphyria. Ranitidine
should therefore be
avoided in patients
with a history of acute
porphyria.
y Potential toxicity results from decreased clearance(elimination) and therefore prolonged action; greatest in
the older adult patients or those with hepatic or renal
dysfunction.
y Lab tests: Periodic liver functions. Monitor creatinineclearance if renal dysfunction is present or suspected.
When clearance is
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Generic name:metronidazole
Brand name: Metronidazole
Drug Classification: Anti-infectives,Anti-protozoals
Dosage: 2.5 ml per IV push
Indication: Amebicide in the management of amebic dysentery
Mechanism of action Side effect and Adverse Reaction Contraindication Nursing Consideration
Disrupts DNA and protein synthesis in
susceptible organisms
Bactericidal, or amebicidal action
CNS: seizures, dizziness, headache
GI: abdominal pain, anorexia,
nausea, diarrhea, dry mouth, furry
tongue, glossitis, unpleasant taste,
vomiting
Hematologic: leukopenia Skin: rashes, urticaria
hypersensitivity Administer with food or milk to minimize GI
irritation. Tablets may be crushed for
patients with difficulty swallowing.
May cause dizziness or light-headedness.
Caution patient or other activities requiringalertness until response to medication is
known.
Inform patient that medication may cause
an unpleasant metallic taste.
Inform patient that medication may cause
urine to turn dark.
Advise patient to consult health care
professional if no improvement in a few
days or if signs and symptoms of
superinfection (black furry overgrowth on
tongue; loose or foul-smelling stools
develop).
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Generic name:Gentamicin
Brand name:Gentamicin
Drug Classification: antiinfective; aminoglycoside antibiotic
Dosage: IV/IM 2 mg/kg followed by 1.5 mg/kg q8hIndication:Parenteral use restricted to treatment of serious infections of GI, respiratory, and urinary tracts, CNS, bone, skin, and soft tissue (including
burns) when other less toxic antimicrobial agents are ineffective or are contraindicated. Has been used in combination with other antibiotics. Also
used topically for primary and secondary skin infections and for superficial infections of external eye and its adnexa.
Mechanism of action Side effect and Adverse Reaction Contraindication Nursing Consideration
Broad-spectrum aminoglycoside
antibiotic derived
fromMicromonospora
purpurea. Action is usuallybacteriocidal.
Special Senses: Ototoxicity (vestibular
disturbances, impaired hearing),
optic neuritis. CNS: neuromuscular
blockade: skeletal muscle weakness,apnea, respiratory paralysis (high
doses); arachnoiditis (intrathecal
use). CV: hypotension or
hypertension. GI: Nausea, vomiting,
transient increase in AST, ALT, and
serum LDH and bilirubin;
hepatomegaly, splenomegaly.
Hematologic: Increased or decreased
reticulocyte counts;granulocytopenia, thrombocytopenia
(fever, bleeding tendency),
thrombocytopenic purpura, anemia.
Body as a Whole: Hypersensitivity
(rash, pruritus, urticaria, exfoliative
dermatitis, eosinophilia, burning
sensation of skin, drug fever, joint
pains, laryngeal edema, anaphylaxis).
Urogenital: Nephrotoxicity:proteinuria, tubular necrosis, cells or
casts in urine, hematuria, rising BUN,
nonprotein nitrogen, serum
creatinine; decreased creatinine
clearance.
History of hypersensitivity to or toxic
reaction with any aminoglycoside
antibiotic. Safe use during pregnancy
(category C) or lactation is notestablished
Dosages are generally adjusted to
maintain peak serum gentamicin
concentrations of 4 10 g/mL, and
trough concentrations of 12 g/mL.Peak concentrations above 12 g/mL
and trough concentrations above 2
g/mL are associated with toxicity.
Draw blood specimens for peak
serum gentamicin concentration 30
min1h after IM administration, and
30 min after completion of a 3060
min IV infusion. Draw bloodspecimens for trough levels just
before the next IM or IV dose. Use
nonheparinized tubes to collect
blood.
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X. List of Identified Problem according to priorityBased on my own arrangement, I will priorities the ff:
y Acute pain r/t muscle spasm and movement of bone fragment secondary to tissue traumay Impaired physical mobility r/t neuromuscular/skeletal impairmenty Risk for infection r/t open wound present on the affected area
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XI. Nursing Care PlanCues Scientific
Background
Nursing Diagnosis Plan Intervention Rationale Evaluation
S:
ang sakit ng
Nabunggong paa
ko
O:
-grimace noted
-body weakness
-pain rate at 7/10
-irritability- self-focus behavior
The remaining
fragment of bones
in the Fractured
area gives an
internal trauma
that leads to
muscular spasm as
an action of our
body that triggersthe pain receptor
on the fracture site
Acute pain R/T
muscular spasm and
movement of bone
fragment secondary to
tissue trauma
After 2 hr. of
rendering nursing
intervention,
patient will relief
from pain and to
avoid any afflicted
trauma as
necessary
-Instruct to have a
complete bed rest
as needed
-Asses pain scale
-Administer
Analgesic As order
-Encourage to do
any devertional
activities like
playing card game,
watching TV and
Etc.
-advice watcher to
stand by at the side
of the patient
during in pain
- to promote
quicker bone
healing and
avoidance for any
bone fragment
motility
-to asses the Level
of pain
-stimulate theprostaglandine to
produce peripheral
mediated analgesia
-to divert the
attention and
stimulant of the
pain
-serves as support
to lift up and
psychologically
decreases the level
of pain
Goal met, patients
pain sca subsided at
7/10 to 5/10 and
also avoided any
tissue trauma
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Cues Scientific
Background
Nursing Diagnosis Plan Intervention Rationale Evaluation
S:ang hirap palang
igalaw tong paa
ko,pag gumagalw
kasi masakit
O:
-limited moved
noted
-slow and
uncoordinativemovement noted
-lack of implied
activity during day
time
-with an functional
level of 3
Due to nerveddamage, nerve on
the affected side
has no proper
coordinative
stimulation and
movement but it
just trigger the pain
receptor during any
movement at all
Impaired physicalmobility r/t
neuromuscular/skeletal
impairment
After 2 months ofrendering nursing
care, patient will
understand the
situation regarding
to his treatment,
safety measure and
risk about his
condition and
enable to recoveryhis activity as
quickly and
necessary
-provide relaxationof the affected
extremities
-use the un affected
side for making any
activity even on bed
-assist patient in all
of his/her daily
activity
-if the patient is for
any orthopedic
procedure, explain
The significance of
the procedure
-encourage to
increase intake of
calcium
-to promote bonehealing
-to promote semi-
independent
encouraging
-to avoid any
mistake that may
lead to server
problem-to orient the
patient about the
quickest way to
recover
-calcium promotes
growth and
development of the
bones
Goal met, as daypast by the patient
recovers quickly
and can walk with
the use of
equipment or none
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Cues Scientific
Background
Nursing Diagnosis Plan Intervention Rationale Evaluation
O:-Open Wound
-Stasis on the
Affected side
A presence of anportal of exit and a
stasis with moisture
of the discharge of
the wound may lead
to high tendency of
getting a infection
Risk for infection r/topen wound present
on the affected area
After 1 hr. ofrendering
collaborative
teachings, the pt.
will respond and
understand the
teaching regarding
to his condition
-teach pt. aboutclean and dry
wound care
-advise pt. to
control his
environment
-advise pt. to
complete his
medication mostlyanti-bacterial
-alternate position
changing in the
affected side
-to avoid moisturein the wound
-a high tendency of
avoiding infection is
to maintain clean
surrounding
-to ensure the
avoidance of the
infection
-avoid bedsore
Goal met, the pt. isresponsive and
understand well all
the teachings
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XII. On-going AppraisalBased on my one day observation, the patient is determine to recover as soon as possible because he is getting bored when he stay at the
hospital
XIII. Discharge Plan:This are interventions and teaching that the pt. needed in home recovery state:
y Teach pt. for early ambulationy Teach pt for increase calcium intakey Teach pt. about less over work on the affected sidey Advise for completing the home regimeny Teach pt. about proper wound carey Advice about the monthly check up regarding about his right leg