CUES Subjective: Oo, Masakit parin yung paa ko, dito banda oh.

Objectives: Rated pain at a scale of 1 out of 3, wherein: 3 = severe pain, 2 = moderate pain, 1 = slight pain and 0 = no pain. With Steinman pin inserted at the right upper femur and with Balanced Skeletal Traction (+) facial Grimace (+) Dysphagia

NURSING DIAGNOSIS A1: Acute pain related to soft tissue trauma and immobility secondary to Fracture.

LONG TERM P1: The patient will be able to know on what are the necessary interventions that should be done when pain is present and the patient will not be able to experienced pain on the fractured site.

SHORT TERM

INTERVENTIONS

RATIONALE

EVALUATION

P1: Within the 8 -Initiate NPI hour shift, the pt will verbalize decreased pain -Assess pt. Level of from 1 to 0. pain

-To establish Rapport -For continuous monitoring -For continuous pt. monitoring

-V/S monitored q4 and recorded especially RR and PR -Noted I and O

Long term: The patient will not experience pain at the fracture area after 2 months of proper intervention. Short Term: The patient will verbalize a decrease in the degree of pain from 2/3 to 1/3.

- For continuous pt. monitoring -Minimize stimulation and promote relaxation -Measures that reduce cerebral vascular presence and that slow or block sympathetic response are effective in relieving headache and

-Will encourage and maintain bedrest during acute phase. -Will provide and recommend nonpharmacological measures for relief of headache, such as placing a cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation

technique, such as guided imagery and distraction; and diversional activities.

associated complications.

-Will advice to eliminate or minimize vasoconstricting activities that may aggravate headache, such as straining at stool, prolonged coughing, and bending over. -Will administer analgesics, as prescribed. .

-Activities that increase vasoconstriction accentuate the headache in the presence of increase cerebral vascular pressure. - Reduce or control pain and decrease stimulations of the sympathetic nervous system.

Subjective: Nagagalaw ko naman ang aking mga daliri sa paa, pero mahirap pa din gumalaw Objectives: With Steinman pin inserted at the right upper femur and with Balanced Skeletal Traction (-) Ambulatory

A2: Impaired Physical Mobility related to tissue trauma secondary to fracture

P2: After 3 months of interventions and continuous physical therapy, the patient will be able to regain and maintain mobility at the highest possible level.

P2: After 8 hours of rendering appropriate nursing care, the patient will participate in passive ROM exercises

-Initiate NPI

-To establish Rapport

-Assess Assess the degree of mobility produced by the injury

Long Term: The patient will be able to -Patient may be regain and restricted by maintain mobility self- view or self at the highest perception out of possible level proportion with actual physical Short Term: limitations, The Patient will requiring participate in information and passive ROM interventions to exercises promote progress toward wellness -Optimal ROM is critical for movement and necessary for rehabilitation -For continuous pt. monitoring - For continuous pt. monitoring -The rehabilitation

-Assess ROM of unaffected parts proximal and distal to immobilization device.

-V/S monitored q4 and recorded especially RR and PR -Noted I and O -Assess muscle

strength in all extremities

program will be geared toward maximizing strength in the unaffected extremities and maintain as much strength as possible in the affected extremity -Provides opportunity for release of energy and aids in reducing social isolation. -Increase blood flow to the muscles and bones to improve muscle tone, maintain joint mobility, and prevent contractures and atropy and calcium resorption from disuse

-Encourage participation in recreational activities

. -Assist with ROM exercises of affected and unaffected extremities

-Turning patient from side to side

-Prevents or reduces incidence of skin and respiratory complications

-Consult with physical or occupational therapist and/or rehabilitation specialist

-useful in creating aggressive individualized activity.

CUES

NURSIN G DIAGNO SIS Risk for infection related to presence of site for organism invasion

LONG TERM

SHORT TERM

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Nilagyan ako ng bakal na to oh. Objectives: -Received patient on bed in semifowlers position -Conscious, coherent and communicative, oriented to time, place and person - With Steinman pin inserted at the right upper femur and with Balanced Skeletal Traction

At the end of the nursing intervention the pt will be able to enumerate the different way s on how to prevent infection

At the end of the shift the pt will not manifest any signs of infection.

- Instructed the pt and relatives to limit visitors

-Protect client from potential sources of pathogens and infection. -Prevents cross contamination and reduce risk of infection.

-Demonstrate and required good handwashing protocol for all visitors

Long Term: The Patient will be able to enumerate the different ways on how to prevent infection Short Term: The Patient will not manifest any signs of infection.

-Monitored Temperature

-to monitor signs of infection, elevated temperature or hyperthermia is a sign of infection. -Prevents stasis of respiratory secretions, reducing risk of atelectasis and pneumonia. -Early intervention is essential to prevent

-Encouraged frequent turning and deep breathing

-Auscultated breath

sounds, noted crackles and rhonchi; inspected secretions for changes in characteristics, Observed urine for signs of infection: cloudy, foul-smelling.

sepsis or septicemia in immunosuppressed person.

-Handled client gently and kept linens dry and wrinkle free. -Inspected skin mucous membranes. Provided good oral hygiene. Instructed to use soft toothbrush, sponge or swabs for frequent mouth care.

-Prevents sheet burns and skin excoriation.

-May indicate local infection. The oral cavity is an excellent medium for growth of organisms ans is susceptible to ulceration and bleeding.

-Coordinated procedures and tests to allow for uninterrupted rest periods

-Conserved energy for healing and cellular regeneration.

-Monitored laboratory -Decreased numbers studies(CBC) of normal or mature WBCs can result from the disease process, compromising the immune response increasing risk of infection.