NURSING CARE PLAN CUES/ NEEDS SUBJECTIVE: Masaki ang kanang binti ko, as verbalized by the patient.

Pain range 8/10 as 10 being the highest. OBJECTIVE: *Facial grimace *Protective movement *restlessness *irritability *(+) pain in right leg *with splint and elastic bandage in right leg VS: BP: 120/80 mmHg PR: 82 bpm RR: 19 bpm TEMP: 37.6C LABS: *X-ray *CT scan Reference: Nurses Pocket Guide ed. 11 (pp. 498-503) NURSING DIAGNOSIS Acute pain related to movement of bone fragments. RATIONALE GOAL AND OBJECTIVES After 1 hour of nursing intervention, patient will be able to decrease pain from 8/10 to 3/10 as manifested by: INTERVENTIONS RATIONALE EVALUATION After 1 hour of nursing intervention, goal was met. The patient was able to decreases pain from 8/10 to 3/10 as manifested by: - Report pain is controlled/ relieved. - Relaxed or calmed.

Acute pain caused by unpleasant sensory and emotional experiencing arising from actual or potential tissue damage or described in terms - Report pain is of such damage the controlled/ client is relieved. experiencing pain - Relaxed or calmed.

Assess verbal/ Useful in nonverbal reports evaluating pain of pain noting choice of location, intervention, intensity and effectiveness of duration. therapy Monitor vital signs every 4 hours. Maintain immobilization of affected part by means of bed rest and elastic bandage. Elevate and support injured extremity. To have baseline data. Relieves pain and prevents bone displacement/ extension of tissue injury. Promotes venous return, decreases edema, and may reduce pain. Maintains body warmth without discomfort due to pressure of bedclothes on affected parts. Reduce pain

Elevate bed covers and keep linens off toes.

Apply ice

compress on the affected extremity every 30 minutes Encourage client to discuss problems related to injury.

and swelling.

Helps alleviate anxiety. Client may feel need to relive the accident experience. To promote adequate rest and sleep to facilitate pain relief. Reduces pain and discomfort, enhance rest.

Promote quite and calm environment.

Administer analgesics (e.g dolcet) as indicated

Maintain Perform and strength and supervise passive mobility of or active ROM unaffected exercises on the muscles and unaffected facilitates extremity. resolution of inflammation in injured tissues