NURSING CARE PLANS

CUES NURSING SCIENTIFIC RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective Cue: Acute pain related When your body is injured in some way After 4 hours of nursing Independent After 4 hours of
“Masakit it akon tiil. to muscle spasm or something else is wrong, your nerves interventions, the patient 1. Establish rapport. To build trust and nursing interventions,
Mga 7/10 it kaul-ol." (cells that help your body send and will be able to: connection with the the patient was able
as verbalized. receive information) send millions of patient. to:
messages to your brain about what's 1. report
Objective Cues: going on. Your brain then makes you feel satisfactory pain 2. Assess the client’s Utilize pain intensity 1. report
pain. Feeling pain in response to an injury control at a level description of pain, rating scale including satisfactory
- Facial grimace is a signal that your body has been less than 3 to 4 such as quality, Wong-Baker FACES pain control
- Guarding damaged in some way. on a scale of 0 nature, and severity pain rating scale, at a level less
behaviour to 10. of pain. visual analog scale, than 3 to 4
- Narrowed Source: and FLACC (face, on a scale of
Focus/Self- https://kidshealth.org/en/kids/pain.html 2. report absence legs, activity, crying,
0 to 10.
focusing of pain. consolability) scale.
behavior Take note of the
- Spasm in the relieving and 2. report
right leg aggravating factors absence of
and nonverbal pain pain.
cues such as changes
in vital signs, GOALS MET
emotions, and
behavior. Pain
assessment
determines the
effectiveness of
interventions. Many
factors, including the
level of anxiety, may
affect the perception
of pain.

3. Encourage the Helps alleviate

patient to discuss anxiety. The patient
problems related to may feel the need to
the injury.
 relive the accident
experience.

4. Maintain Immobilization
immobilization of relieves pain and
affected part using prevents bone
bed rest, cast, splint, displacement and
traction. extension of tissue
injury.

5. Elevate and support Promotes venous

injured extremity. return, decreases
edema and may
reduce pain.

6. Avoid the use of Can increase

plastic sheets and discomfort by
pillows under limbs enhancing heat
in the cast. production in the
drying cast.

7. Elevate bed covers; Maintains body

keep linens off toes. warmth without
discomfort due to the
pressure of
bedclothes on
affected parts.

8. Explain procedures Allows the patient to

before starting prepare mentally for
them. activity and to
participate in
controlling the level
of discomfort.

9. Use of non- Alternative therapies

pharmacological such as relaxation,
techniques for pain massage, guided
 management as imagery, or
appropriate. distraction may
decrease pain and
provide comfort.

10. Perform and Maintains strength

supervise active and and mobility of
passive ROM unaffected muscles
exercises. and facilitates
resolution of
inflammation in
injured tissues.

11. Provide alternative Improves general

comfort measures circulation; reduces
(massage, backrub, areas of local
position changes). pressure and muscle
fatigue.

12. Provide emotional Refocuses attention,

support and promotes a sense of
encourage stress control, and may
management enhance coping
techniques abilities in managing
(progressive the stress of
relaxation, deep- traumatic injury and
breathing exercises, pain, which is likely to
visualization, or persist for an
guided imagery). extended period.

13. Identify diversional It prevents boredom,

activities reduces muscle
appropriate for tension, and can
patient age, increase muscle
physical abilities, strength; it may
and personal enhance coping
preferences. abilities.
 14. Apply cold or ice Reduces edema and
pack first 24–72 hr hematoma formation
and as necessary. decreases pain
sensation. The
duration of
application depends
on the degree of
patient comfort and
as long as the skin is
carefully protected.

Dependent: Antispasmodic and

1. Administer analgesic agents are
analgesics (e.g., useful in relieving
acetaminophen) or bladder irritability,
antispasmodics (e.g., spasm, and pain.
phenazopyridine),
as indicated.
Short-course therapy
2. Administer using a single
antibacterial agents antibiotic or a 3-day
as indicated. course reduces
treatment cost,
increases compliance
to therapy, and a
lower rate of side
effects.

Collaborative:

1. Monitor laboratory WBC count.

and diagnostic Increased WBC count
studies, as indicated: is a systemic
response to infection.
 CUES NURSING DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
Subjective Cue: Disturbed sleep pattern Insomnia is a major contributor to both After 2 days of nursing Independent After 2 days of
“Ginkukurian ak related to current health unintentional fatal injuries in general interventions, the patient 1. Establish rapport. To build trust and nursing interventions,
pagkaturog kay condition as well as fatal motor vehicle injuries. will be able to: connection with the the patient was able
tungod nga may Increasing public health awareness patient. to:
inaabat man ak about insomnia and identifying 1. demonstrate
nga maul-ul." as persons with insomnia may be improved 2. Assess the patient’s Sleep patterns may 1. demonstrate
verbalized important in preventing unintentional relaxation and sleep pattern and vary for each improved
fatal injuries. sleep. take note of the individual. Evaluating relaxation
Objective Cues: following: the these patterns will and sleep.
- Puffy eyes Source: 2. verbalize the amount of sleep, provide general
- Restlessness https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196061/ effectiveness of position, sleep information and 2. verbalize
- Awakening pain relief. routine, position, details on certain the
at an depth, extent, and areas of sleep that effectiveness
earlier time interferences. need to be addressed of pain
or or improved. relief.
sometimes
later on 3. Assess the patient’s Noting the features of
than what pain characteristics pain would help
is desired or features (e.g., provide insight and
or severity, onset, aid pain
considered duration, relieving management.
normal facets, and Managing pain is one
- Struggle location). way to reduce the
with patient’s pain
arousal experience,
associated with
impedance and
disruption of the sleep
cycle or rest periods.
Having a better
understanding of the
nature of pain can
help adjust treatment
to provide pain relief.

4. Observe for any To attain baseline

signs of sleep- information for the
wake problems.
 Note the patient’s investigation of
hours of sleep. insomnia.

5. Take note of the To aid with insomnia

physical (e.g., evaluation and help
background noise, with its management.
discomfort,
frequent urination
during bedtime,
pain) or
physiologic factors
(e.g., fear, anxiety)
that hinders sleep.

6. Educate the patient It is important to

on several mention the needed
measures for sleep precautions and
promotion, such as reminders to better
avoiding heavy promote sleep.
meals, smoking Beverages such as
before bedtime, tea, chocolate, colas,
caffeine-containing and coffee contain
beverages, and caffeine that
alcohol. Also, activates and
mention proper energizes the nervous
fluid and food system. Whereas
intake. taking full meals
before bedtime may
induce indigestion or
an upset stomach,
hindering sleep onset.
Alcohol should also be
avoided, albeit its
ability to induce
sleep, since it
hampers REM sleep.
7. Encourage the Adhering to a
patient to adhere consistent sleep and
to a dedicated and rest schedule helps
consistent sleep regulate and manage
and rest schedule. the circadian rhythm.
It is also likely to
reduce energy
fluctuations or
consumption required
for adaptation to
alterations.
Meanwhile, drinking a
glass of milk has been
correlated with sleep
promotion, mainly
because of its L-
tryptophan
component.

8. Suggest Pain management

nonpharmacologic strategies do not
interventions (e.g., solely center on
massage, guided pharmacologic
imagery, cold interventions. It could
applications) to also be in another
ease the pain. form, such as non-
pharmacological
means. Exploring
these options (e.g.,
massage, guided
imagery, progressive
relaxation, heat, and
cold applications) can
provide adequate
pain management.
These strategies act
by reducing pain,
muscle tension, and
 inflammation which
can later affect the
patient’s sleep,
peace, or relaxation
if not addressed
beforehand.

Dependent:
1. Administer Antispasmodic and
analgesics (e.g., analgesic agents are
acetaminophen) or useful in relieving
antispasmodics bladder irritability,
(e.g., spasm, and pain.
phenazopyridine),
as indicated.

Collaborative:
1. Talk to the patient To lessen the burden
and his/her family of suffering due to
or. Suggest chronic pain and
participating in allow a reinforcing
support for people support system to
who bear pain. help with rest and
recreation.
 CUES NURSING DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
Subjective Cue: Risk for falls Scientists have linked several personal After 2 days of nursing Independent After 2 days of
“Diri ko nakikiwa risk factors to falling, including muscle interventions, the patient 1. Establish rapport. To build trust and nursing interventions,
tak tiil. Di ko pa weakness, problems with balance and will be able to: connection with the the patient was able
kaya tumukdaw gait, and pain due to physical injuries. patient. to:
ngan lumakat." as 1. maintain
verbalized Source: stabilization 2. Maintain bed rest Provides stability, 1. maintain
https://www.nia.nih.gov/health/prevent-falls- or limb rest as reducing the stabilization
Objective Cues: and-fractures 2. demonstrate indicated. Provide possibility of
- Right leg body mechanics support of joints disturbing alignment 2. demonstrate
spasm that promote above and below and muscle spasms, body
- Weakness stability the fracture site, which enhances mechanics
in lower especially when healing. that promote
extremities moving and stability
- Inability to turning.
move both GOALS
legs 3. Secure a bed A soft or sagging PARTIALLY
board under the mattress may deform MET
mattress or place a wet (green) plaster
the patient on the cast, crack a dry cast,
orthopedic bed. or interfere with
traction pull.

4. Support fracture Prevents unnecessary

site with pillows or movement and
folded blankets. disruption of
Maintain a neutral alignment. Proper
position of the placement of pillows
affected part with also can prevent
sandbags, splints, pressure deformities
trochanter roll, in the drying cast.
footboard.

5. Use sufficient Hip, body, or multiple

personnel when casts can be
turning. Avoid extremely heavy and
using an abduction cumbersome. Failure
bar when turning a to properly support
limbs in casts may
 patient with a cause the cast to
spica cast. break.

6. Observe and Coaptation splint

evaluate splinted (Jones-Sugar tong)
extremity for may be used to
resolution of immobilize fracture
edema. while excessive tissue
swelling is present. As
edema subsides,
readjustment of splint
or application of
plaster or fiberglass
cast may be required
for continued
alignment of the
fracture.

7. Maintain position Traction permits

or integrity of pulling on the
traction. fractured bone’s long
axis and overcoming
muscle tension or
shortening to
facilitate alignment
and union. Skeletal
traction (pins, wires,
tongs) permits
greater weight for
traction pull than can
be applied to skin
tissues.

8. Ascertain that all Ensures that traction

clamps are setup is functioning
functional. properly to avoid
Lubricate pulleys interruption of
and check ropes
 for fraying. Secure fracture
and wrap knots approximation.
with adhesive
tape.

9. Position the Promotes bone

patient, so that alignment and
appropriate pull is reduces the risk of
maintained on the complications
long axis of the (delayed healing and
bone. nonunion).

10. Review restrictions Maintains integrity of

imposed by pull of traction.
therapy such as not
bending at the
waist and sitting up
with Buck traction
or not turning
below the waist
with Russell
traction.

11. Assess the integrity Hoffman traction

of the external provides stabilization
fixation device. and rigid support for
fractured bone
without ropes, pulleys,
or weights, thus
allowing for greater
patient mobility,
comfort and
facilitating wound
care. Loose or
excessively tightened
clamps or nuts can
alter the compression
 of the frame, causing
misalignment.

Independent:
1. Administer pain Painkillers, such as
medications, as paracetamol, can be
ordered. used to help ease the
pain. Ibuprofen and
other non-steroidal
anti-inflammatory
drugs (NSAIDs)
tablets or creams can
also be used to ease
pain and reduce any
swelling.

Collaborative:
1. Talk to the patient To lessen the burden
and his/her family of suffering due to
or. Suggest chronic pain and
participating in allow a reinforcing
support for people support system to
who bear pain. help with rest and
recreation.

2. Review follow-up Provides visual

and serial X-rays. evidence of proper
alignment or
beginning callus
formation and
healing process to
determine the level of
activity and need for
changes in or
additional therapy.