NURSING CARE PLAN

UNIVERSITY OF CEBU- BANILAD

Patient’s Name: Jaluag, Vhan Yhuri Hospital No.: 33068

Age: 10 Room No: 530
Impression / Diagnosis: Fracture lateral condyle at left elbow
Physician: Dr. Veloso
Nurse’s Name and Signature: Germin E. Cesa

CLINICAL PORTRAIT PERTINENT DATA

During my first contact with the patient, the patient is wide awake and in bedrest. His A case of Mr. Vhan Yhuri Jaluag, 10 yrs., recently residing at Minglanilla, Cebu. Patient
movements are slow because of the fracture at his left elbow. He said that the pain is so was playing in the monkey bars in the school and fallen on the ground that cause an
painful that he is afraid to move his left arm. He will be undergoing an operation called injury in his left elbow resulting a fracture in the lateral condyle of the left elbow.
“Open reduction internal fixation – pinning (minimal risk)”.
Laboratory results:
Vitals taken: Blood test (11/20/2022)
X-ray scan (11/20/2022)
BP = 110/80
Ox stat = 97%
HR = 99
RR = 21
Temp = 36.5
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD

CUES NURSING SCIENTIFIC BASIS GOAL AND OUTCOME NURSING ACTIONS & RATIONALE OF EVALUATION
DIAGNOSIS CRITERIA NURSING ORDERS NURSING DIAGNOSIS

S - the patient Fracture lateral Lateral condyle The patient’s pain and To encourage the best possible The following should
verbalized “ouch! It condyle at left fractures are the discomfort will be gone level of function and prevent be evaluated for a
hurts so much.” elbow, patient is further complications:
second most common and the fracture in the successful
needed to be elbow fracture after lateral condyle of the left implementation of the
operated called the supracondylar elbow will be treated so care plan.
“Open Reduction -Assess for pain. -to have the knowledge of
humerus fracture in the patient
Internal Fixation – the severity of the
Pinning”. children. This -Pain was relieved.
fracture pattern is -Identify negative patient’s pain. -Achieved a pain-free,
typically through the factors affecting functional, and stable
O – normal heart -Assess the degree of physical -to determine the location
lateral metaphysis patient’s pain and body part.
rate, no signs of limitation and severity of the
extending into the eliminate or reduce -Maintained asepsis.
elevated blood their effects when fracture as well as pain -Maintained vital
epiphysis and often
pressure. Normal possible. and swelling signs within normal
extends into the
vital signs. articular surface. -Participate willingly in range.
Patient can talk They are associated necessary/desired -Assess for pain or other -to prevent the patient -Exhibited no
and walk with no activities. psychological concerns. from moving for this will evidence of
with higher
movement on his -Make report when cause pain and complications.
complications than
left elbow. patient experience any discomfort. Depression
other elbow fractures,
and anxiety may also
thus it is critical to discomfort or any
prevent purposeful
appropriately difficulties.
movement.
diagnose and treat. -Demonstrate a
decrease in
-Monitor Vital signs -to check for the vital
physiological signs of
signs and ensure the
intolerance (e.g., pulse, wellness of the patient.
Doenges, M. E., respirations, and blood
Moorhouse, M. F., & pressure remain within -Assess pain relief -to assess the
Murr, A. C. (2008). client’s normal range).
V/S taken as effectiveness of the
Nurse’s Pocket Guide
follows: medication or
Diagnoses,
intervention
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD

Prioritized -Assess for a support system -to avoid any problems if

Interventions, and there will be no one taking
T= 36.5 degree Rationales (11th ed.). care of the patient at
Celsius F. A. Davis his/her home.
Company.
-Administer analgesics -to treat inflammation and
experience pain relief to
PR= 99 the patient.
RR= 21
BW:
-Provide comfort to the patient -to alleviate patient’s
comfort and to stay away
from complications

-Support the injured area -to promote healing and

avoid any injury or worsen
the status of the patient.

-Instruct on medication on
discharge
- Patients should be
instructed to not take pain
medications more
frequently than
prescribed. If the dose
ordered is not controlling
their pain, they should
contact their provider.

-to fully support and give

-Encourage the use of assistive comfort to the patient.
devices and equipment.
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD

Patient’s Name: Mary Mellenine Flores Hospital No.:

Age: 23 Room No: 618
Impression / Diagnosis: Cerebral Concussion Secondary to fall
Physician: Teresita Galindo Alfafara

Nurse’s Name and Signature: Kiara Marie Cola

CLINICAL PORTRAIT PERTINENT DATA

During my first contact with the patient, she was lying on bed awake, conscious, looking A case of Ms. Mary Mellenine Flores, 23 yrs., recently residing at Minglanilla, Cebu.
fatigue with Paracatemol IV at 20ggts/min infusing well. She was attentive but had little Patient while practicing for their gymnastics stunt for intramurals accidentally slipped
difficulty to movement during vital signs taking. for the hands of her colleague with her neck and head landing first on the ground, loss
consciousness for a few seconds, vomited around 7 times, admitted.
Vitals taken:
Laboratory results:
BP = 120/80
Ox stat = 99
HR = 64
RR = 15
Temp = 35.5
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD

CUES NURSING SCIENTIFIC BASIS GOAL AND OUTCOME NURSING ACTIONS & RATIONALE OF EVALUATION
DIAGNOSIS CRITERIA NURSING ORDERS NURSING DIAGNOSIS

S- Impaired Impaired physical The patient will To promote optimal level of • Responses to
Physical mobility is a common demonstration active function and prevent interventions,
Mobility related nursing diagnosis participation in necessary complications: teaching, and actions
to decrease in found among most and desired activities and performed
muscle strength patients at one time or demonstrate increase in • Assist with treatment of • Attainment or
as evidenced by another. It can be a activity levels by underlying condition(s) progress toward
slow movement temporary, permanent - to promote mobility and desired outcome(s)
O – Inability to or worsening problem • Verbalize willingness to • Ascertain that dependent • Modification to plan
move client is placed in best bed for enhance environmental
and has the potential participate in repositioning of care
purposefully situation (e.g., correct size, safety.
to create larger issues program.
within the such as skin • Verbalize understanding support surface, and mobility
physical breakdown, of situation and risk functions)
environment, infections, falls, and factors, individual - to improve circulation,
including bed social isolation. therapeutic regimen, and • Change client’s position reduce tightening
mobility safety measures. frequently, moving individual of muscles and joints,
Doenges, M. E., • Demonstrate techniques parts of the body (e.g., legs, normalize body tone, and
Moorhouse, M. F., & and behaviors that enable arms, head) using appropriate more closely simulate body
Murr, A. C. (2008). safe repositioning. support and proper body positions an individual
V/S taken as Nurse’s Pocket Guide • Maintain position of alignment. Encourage periodic would normally use.
follows: Diagnoses, Prioritized function and skin integrity changes in head of bed (if not
Interventions, and as evidenced by absence contraindicated by conditions
Rationales (11th ed.). of contractures, foot drop, such as an acute spinal cord
F. A. Davis decubitus, and so forth. injury), with client in supine
T= 35.5 degree
Company. • Maintain or increase and prone positions at - to assist movements;
Celsius intervals reposition in good
strength and function of
affected and/or body alignment, using
compensatory body part. • Turn dependent client appropriate supports.
frequently, utilizing bed and
PR= 64
mattress positioning settings
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD

RR= 15 - to provide support for the

BW: client’s body and to
• Instruct client and caregivers prevent injury to the lifter.
in methods of moving client
relative to specific situations
(e.g., turning side to side,
prone,
or sitting) -to reduce pressure on
sensitive areas and prevent
• Perform and encourage development of problems
regular skin examination for with skin or tissue integrity.
reddened or excoriated areas.
Use a pressure-risk assessment
scale as appropriate. Provide - to maintain joint mobility,
frequent skin care improve circulation, and
prevent contractures.
• Provide or assist with daily
range-of-motion interventions
(active and passive - to facilitate
elimination.
• Assist with activities of - to permit maximal effort
hygiene, feeding, and and involvement in activity.
toileting, as indicated. Assist
on and off bedpan and into
sitting position (or use cardio - to adjust care as indicated.
position bed or foot-egress
bed) - to decrease boredom and
potential for depression.
• Administer medication prior
to activity as needed for pain
relief
- to promote
• Observe for change in safety and timely response.
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD

strength to do more or less

self-care - to communicate
adequately with client.
• Provide diversional activities
(e.g., television, books, games,
music, visiting), as
appropriate,

• Ensure telephone and call

bell are within reach
 NURSING CARE PLAN
UNIVERSITY OF CEBU- BANILAD