NURSING CARE PLAN

PATIENT’S INITIAL: Patient X STUDENT’S NAME: Jesabel V. Tabor

DIAGNOSIS: Fracture Closed Complete Displaced Comminuted Middle 3rd Femoral Shaft YEAR LEVEL: BSN IV

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

SUPPORTIVE DATA NURSING DIAGNOSIS PATIENT GOALS/ NURSING RATIONALE OVSERVATIONS/ CONCLUSIONS
OUTCOME CRITERIA INTERVENTIONS

Subjective:  Acute pain is  To provide 1. Established 1. To gain trust and feeling  Relieving methods and
described as an comfort rapport comfortable relaxation techniques are
 “Masakit ang unpleasant sensory  To monitor 2. Vital signs 2. To obtain baseline data understood and demonstrated.
paa ko” as or emotional vital signs taken and and monitor patient’s  Goal partially met.
verbalized by experience  Instruct to do recorded status
the patient. associated with activities such signs taken 3. To relieve pain and
actual or potential as deep and recorded prevent stiffness the
Objective: tissue damage. breathing 3. Instruct to do stated activities must be
 Conscious exercise activities done.
and coherent  To give health such as deep 4. To provide stability and
 Weak teaching breathing safety.
 Body malaise  To provide exercise
 Afebrile proper 4. To provide
 With 90 90 positioning proper
degree positioning
traction
applied
 Dry and
intact wound
dressing
 V/S take as
follows:

T: 37
P: 128
R: 25