Assessment Nursing Inference Planning Nursing Interventions Rationale Evaluation

Diagnosis
Name: E.C> Alteration in Fracture on Right After 30 Independent: The goal was
Age: 27 comfort: Leg minutes to 1 1. Monitor vital - To note alterations and partially met. After
Sex. M Acute pain ↓ hour of signs baseline data 2 hours of nursing
related to Redness and nursing - the meaning of the pain interventions, the
Subjective: Fracture on swelling interventions 2. Asses pain will directly influence the pain scale was
“Masakit itong kanang paa Right leg ↓ , the pain characteristics patient’s response reduced from 6/10
ko” –as verbalized by the Stimulation of scale will be to 2/10.
patient nociceptors reduced - Patients may experience
- with pain scale of 6/10 ↓ from 6/10 to 3. Evaluate what an exaggeration to “Di na masyadong
Sending electrical 3/10. the pain means to the pain/decreased ability to masakit.”
Objective impulses to the individual tolerate painful stimuli if - as verbalized by
Vital signs as follows: spinal cord 4. Eliminate environmental the patient
BP: 110/70 ↓ additional stressors or intrapersonal,
PR: 98 Which travels to the sources of discomfort intraphsychic factors are
RR: 17 brain when possible future stressing them.
T: 35.9 °C ↓ -prompt response to
- Observed evidence Causing pain 5. Respond complaint may result in
of pain immediate to decrease anxiety in patient
- Restlessness complaint of pain
- Swelling on right - to alleviate pain and
leg promote blood circulation
6. Apply warm
compress on injured - pain medications such as
area mefenamic acid can help
alleviate pain
Dependent:
1. Give medications as
ordered by doctor.
John Michael H. Tanchuan