A.

NURSING CARE PLANS

BACKGROUND
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
KNOWLEDGE
Subjective: Impaired Skin integrity After 30 minutes of Independent: After 30 minutes of
“Nilagyan ng bakal related to Trauma rendering nursing >examine the skin for  Provide information nursing intervention
ang binti ko ” as immobilization ↓ interventions and open wound, rashes regarding skin the patient was able to
verbalized by the secondary to BST as Vehicular Accident health teachings, the bleeding or circulation and identify management
patient evidenced by tibial pin ↓ patient will identify discoloration problems that may and prevention of
Objective: insertion Fracture of the legs independent require further further skin infection.
 With tibial pin ↓ management and medical intervention
 Difficulty in pain prevention of further Goal met.
changing position ↓ skin infection. >remove excess  This would lead to
while lying on bed body weakness clothing especially the further damage of
 With balanced ↓ rough ones the skin
skeletal traction Immobility
↓ >give bed bath  To promote good
 VS taken as:
Prolonged inability in hygiene
T: 36.5˚C
turning or changing
RR: 19cpm
position >reposition frequently  Lessens constant
PR: 81bpm
↓ pressure on same
BP: 110/70 mmHg
Signs and symptoms area and minimizes
↓ for skin breakdown
impaired skin integrity
>assess position of  Improper
splint ring of traction positioning may
device cause skin
injury/breakdown
 B. NURSING CARE PLANS
BACKGROUND
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
KNOWLEDGE
Subjective: Trauma After 30 minutes of
“Hindi ko na Impaired Physical ↓ After 30 minutes of Independent: rendering nursing
ginagalaw masyado Mobility related to Vehicular Accident rendering nursing >assist patient to do  To increase the interventions and
kasi masakit ,” as prescribed movement ↓ interventions and active/passive ROM blood flow to health teachings, the
verbalized by the restriction as evidenced Fracture of the legs health teachings, the exercise to unaffected muscles and bone to patient was able to
patient. by limited range of ↓ patient will extremities improve muscle tone demonstrate
Objective: motion. bleeding from damaged demonstrate behaviors that enable
 Limited movement ends of bones and behaviors that enable >observe movement of  To note any resumption of
 Difficulty in surrounding tissues resumption of the client incongruence with activities such as
changing position ↓ activities such as report of abilities demonstrating
while lying on bed Stimulates active and passive flexion/extension of
inflammatory response ROM exercise. extremities.
 With balanced >determine presence of  To assess presence of
skeletal traction ↓ complications related to complication
Increase capillary immobility Goal met.
 Inability to permeability
perform ADL’s
↓
 Shows guarding Fluid and cellular
behavior >monitor vital sign  It serves as a baseline
exudation
 Irritable at times ↓ data
VS taken as: Pain
T: 36.5˚C ↓ >Reposition patient  To lessen constant
RR: 19cpm impaired physical frequently pressure on the area
PR: 81bpm mobility and prevent pressure
BP: 110/70 mmHg ulcers.

>Encourage adequate  It promotes well

intake of fluids and being and improves
nutritious foods. healing.