Jawood, Kedren Kent G.

BSN 4B/Sherwin G. Maputol, RN, MAN

Nursing Care Plan

Name: Libuna, Arlene Age: 55 years old

Attending Physician: Dr. Pascua Gender: Female
Chief Complaint: Vehicular Accident Room/Bed No.: 336
Diagnosis: Open Fracture, Proximal Third Tibia, Fibula, Left DOA: March 23, 2023

ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS

Subjective Cue: Acute pain Within 8 hours of nursing Independent: After 8 hours
“Sakit-sakit akon tiil” as related to interventions, the patient will • Monitor Vital Signs of nursing
verbalized by the patient vehicular be able to: interventions,
accident as • Assess and record the the goal met
Pain scale of 10/10 evidenced by • Decrease pain from 10/10 to patient’s level of pain as evidenced
pain scale of <5/10 by patient:
Objective Cues: 10/10 • Assess level of
• Wounded sites: • Absence/minimize facial consciousness • Verbalized
Left leg, gracing, restlessness, and decrease pain
posterior right leg, moaning • Maintain immobilization of scale of 4/10
and right cheek the wounded/affected
• Facial grimacing • Verbalize feeling of relief areas • Absence of
• Restlessness and facial gracing,
moaning • Encourage deep breathing restlessness,
• GCS: 15/15 exercise and moaning
• VS:
- BP: 150/90 • Provide emotional support • Verbalized
- CR: 77 and stress management feeling of
- RR: 22 relief
- T: 36.5 • Position patient in a
- SPO2: 98 comfortable position

• Encourage patient to rest

Jawood, Kedren Kent G.
BSN 4B/Sherwin G. Maputol, RN, MAN
• X-RAY:
Complete oblique
displacement fractures
distal 3rd of left tibia and
fibula
• Keep the environment
calm and quiet
Dependent:
• Administered pain
medication as ordered:
Ketorolac 1 amp IVTT
• Prepare for surgery as
indicated
Jawood, Kedren Kent G.
BSN 4B/Sherwin G. Maputol, RN, MAN
Nursing Care Plan

Name: Libuna, Arlene Age: 55 years old

Attending Physician: Dr. Pascua Gender: Female
Chief Complaint: Vehicular Accident Room/Bed No.: 336
Diagnosis: Open Fracture, Proximal Third Tibia, Fibula, Left DOA: March 23, 2023

ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS

Subjective Cue: Impaired physical Short Term Goal Independent: Short Term
“Di ko mahulag ang mobility related to Within 8 hours of nursing • Monitor Vital Signs Goal
duha ko katiil sa sobra pain discomfort interventions, the patient will After 8 hours
kasakit” as verbalized as evidenced by be able to regain/maintain • Assist in repositioning the of nursing
by the patient difficulty of mobility at the highest patient regularly, interventions,
moving the lower possible level of affected encourage coughing and the goal met
extremities body part as evidenced by: deep breathing exercises as patient able
Objective Cues: to regain/
• Wounded sites: • Verbalize understanding of • Perform or demonstrate maintain
Left leg, situation and individual ROM exercises mobility at the
posterior right treatment regimen and highest
leg, and right safety measures • Provide for safety possible level
cheek measure such as raising of affected
• Decreased range of • Ability to move the affected the side rails or pillows on body part as
Motion body parts with minimal patient’s sides evidenced by:
• Difficulty of moving discomfort
the lower extremities • Encourage the patient • Verbalized
• Facial grimacing • Demonstrate techniques or adequate intake of fluids understanding
• Restlessness and behaviors that enable and nutritious food of situation
moaning resumption of activities and individual
• GCS: 15/15 • Encourage the patient to treatment
• VS: have regular exercise after regimen and
Jawood, Kedren Kent G.
BSN 4B/Sherwin G. Maputol, RN, MAN
- BP: 150/90 surgery safety
- CR: 77 Long Term Goal measures
- RR: 22 After 2-3 weeks of nursing • Schedule activities with
- T: 36.5 interventions, the patient will adequate rest period • Ability to
- SPO2: 98 be able to improve physical moved the
mobility as evidenced by: • Monitor and record the affected
client’s ability to move body parts
• X-RAY: • Ability to perform ROM extremities with minimal
Complete oblique exercises discomfort
displacement • Encourage participation in
fractures • Participate ADLs and diversional or recreational • Demonstra-
distal 3rd of left tibia desired activity activities, maintain a ted
and stimulating environment techniques
fibula • Maintain position of function or behaviors
and skin integrity • Assist with self-care that enable
activities resumption of
• Ability to walk the patient activities
with assistive device Dependent:
• Prepare for surgery as Long Term
indicated Goal
After 2-3
• Insert foley catheter as weeks of
ordered nursing
interventions,
• Demonstrate and assist the patient
patient on how to use able to
assistive devices such as improved
wheelchair or crutches physical
mobility as
• Collaborate with physical evidenced by:
therapist for development
of mobility plan • Ability to
performed
Jawood, Kedren Kent G.
BSN 4B/Sherwin G. Maputol, RN, MAN
ROM
exercises

• Participated
ADLs and
desired
activity

• Maintained
position of
function
and skin
integrity

• Ability to
walked the
patient with
assistive
device
Jawood, Kedren Kent G.
BSN 4B/Sherwin G. Maputol, RN, MAN
Nursing Care Plan

Name: Libuna, Arlene Age: 55 years old

Attending Physician: Dr. Pascua Gender: Female
Chief Complaint: Vehicular Accident Room/Bed No.: 336
Diagnosis: Open Fracture, Proximal Third Tibia, Fibula, Left DOA: March 23, 2023

ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS

Subjective Cue: Risk for Within 8 hours of nursing Independent: After 8 hours
“Napilasan akon itsura kag Infection interventions, the patient will • Monitor Vital Signs of nursing
duha ko katiil” as related to be able to: interventions,
verbalized by the patient traumatized • Observe and report signs the goal met
tissues • Remain free from signs and and symptoms of infection as evidenced
Objective Cues: secondary to symptoms of infection by patient:
• Open wounded sites: vehicular • Assess muscle tone,
Left leg, accident • Maintain white blood cell reflexes, and ability to • Remained
posterior right leg, count within normal limits speak free from
and right cheek signs and
• Note and report laboratory symptoms of
• VS: values (e.g. CBC) infection
- BP: 150/90
- CR: 77 • Instruct the patient not • Maintained
- RR: 22 to touch the wound sites white blood
- T: 36.5 cell count
- SPO2: 98 • Use sterile technique when within normal
contact with patient limits

• Instruct family to ensure

the client’s appropriate
hygienic care by
demonstrate appropriate
Jawood, Kedren Kent G.
BSN 4B/Sherwin G. Maputol, RN, MAN
care of infection-prone sites

Dependent:
• Institute prescribed
isolation procedures

• Insert foley catheter as

ordered

• Administered medications
as ordered:
Cefazolin 1 g IVTT
Tetanus Toxoid 0.5 IM
HTIG 250 iu

• Prepare for surgery as

indicated