Assessment Nursing Goal Planning Implementation Rationale Evaluation

Diagnosis
Subjective Acute pain To reduce 1. Assess the general 1. Assessed the 1. It will help The pain
data: related to the pain condition of the general condition to obtain base level is
Patient says he destruction of level. patient. of the patient. line data. improved to
is feeling pain bone and soft 2. Provided total some extent.
at the site of tissue of right 2. Provide total bed bed rest to the 2. It helps in
fracture. leg as rest to the patient. patient. the healing
evidenced by process quikly.
Objective X ray reports 3. It helps in
data: and 3. Monitor vital 3. Monitored assessment of
On examination. signs such as B.P, vital signs such patient vitals.
observation I temperature, as B.P,
found the pulse, respiration. temperature,
patient’s pain pulse,respiration.
level is high at 4. Provide analgesics 4. Provided 4.It helps in
the fracture as per physicians analgesics as per pain relieving.
site. order. physicians order.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis
Subjective Impaired To 1. Assess the general 1. Assessed the 1. It will help Patient’s
data: physical improve condition of the general to obtain the physical
Patient says activity related the patient. condition of the base line data. activity is
that he is to physical patient. improved to a
unable to immobilization activity 2. Provide proper 2. Provided 2. It will help to great extent.
move right of bone as of the positioning to client proper avoid skin
leg. evidenced by patient. every two hours. positioning to damage.
application of client every two
Objective external and hours.
data: plaster cast. 3. Provide possible 3. Provided 3. It will help in
on observation exercise to patient. possible the smooth
I found that exercise to flow of blood
patients right patient. and prevent
leg is in pain. pressure sores.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis
Subjective Risk for To 1. Assess the 1. Assessed the 1. It will help to The risk for
data: infection reduce condition of the condition of the improve the infection is
Patient related to the risk patient. patient . further reduced to
complaints infection and of treatment. some extent.
about damage of skin infection. 2. Assess the 2. Assessed the 2. It will help to
swelling. as evidenced by inflammation and inflammation assess the
direct open wounds. and open wound.
Objective observation. wounds
data:
On 3. Maintain proper 3. Maintained 3. It will help
observation I hygiene. proper hygiene. maintaining
found that proper hygiene
there is 4. Provided of patient .
damage of 4. Provide infection infection free
tissue and free bed linen to the bed linen to the 4. It will help to
inflammation. patient. patient. prevent the
infection