B. NURSING CARE PLANS CUES Subjective: “Hindi ko na ginaga ginagalaw law masya masyado do kasi kasi masa masaki kitt ,” as verb verbal aliz ized ed by the the patient. Objective: Limited movement • Difficulty in • changing position while lying on bed • With balanced skeletal traction in right leg • Inability to perform ADL’s VS taken as: T:36.2oC RR:26cpm PR: 95bpm BP: 13O/9OmmHg • shows guarding behavior •
irritable at times
Nursing Diagnosis P- Impaired Physical Mobility E- related to musculoskeletal impairment S- as evidenced evidenced by verbalization of limited range of motion.
Scientific Background
Risk factor:elderly
Accident/Slipped
bone fracture
pain
extremities do not function properly
Objectives
Date: June 9,2O1O Time: 7am Shift: 6-1OAM
After 30 minutes of rendering nursing interventions and health teachings, the patient will demonstrate behaviors that enable resumption of activities such as active and passive ROM exercise.
Nursing Interventions Independent: >assis >assistt patien patientt to do active active/pa /passi ssive ve ROM ROM exercise to affected and unaffected extremities
>observe movement of the client
>assist client or encourag encouragee client client to do self care activities like bathing
Rationale
Date: June 9,2O1O Shift: 6-1OAM
To increase the blood flow to muscles and bone to improve muscle tone
To note any incongruence with report of abilities
To improve muscle strength circulation and promote self directed wellness
>monitor vital sign
Evaluation
It serves as a baseline data
To optimize circulation >Turn and reposition reposition to all tissues and patient prevent bedsores.
Goal met as evidenced by demonstrating flexion/extension of extremities and able to care one self by bathing himself and combing himself
NURSING CARE PLANS CUES
Nursing Diagnosis
Subjective: s“Nilagyan ng steinmann pin ” as verbalized by the nephew. Objective: • With steinmann pin at right distal femur • Difficulty in changing position while lying on bed • With balanced skeletal traction • VS taken as: T:36.6oC RR:23cpm PR: 90bpm BP: 12O/9OmmHg
P- Impaired Skin Integrity E- related to immobilization secondary to BST S- as evidenced by Steinmann pin insertion
Scientific Background
fracture
pain
body weakness
Objectives
Date: June 10,2O1O Time: 8am Shift: 6-1OAM After 30 minutes of rendering nursing interventions and health teachings, the patient will identify independent management and prevention of further skin infection.
Nursing Interventions Independent: >examine the skin for open wound, rashes bleeding discoloration
>remove excess clothing especially the rough ones >give bed bath
immobility >reposition frequently
Rationale
Provide information regarding skin orcirculation and problems that may require further medical intervention
prolonged inability in turning or changing position >assess position of splint ring of traction device Signs and symptoms
impaired skin integrity
This would lead to further damage of the skin To promote good hygiene Lessens constant pressure on same area and minimizes for skin breakdown Improper positioning may cause skin injury/breakdown
Evaluation
Date: June 10,2O1O Shift: 6-1OAM Goal Met. After 30 minutes of nursing intervention the patient was able to identify management and prevention of further skin infection.
NURSING CARE PLANS CUES Nursing Diagnosis Subjective: P- acute Pain “masakit na masakit na E- related to ineng ,” as verbalized musculoskeletal by the patient. impairment /fracture Objective: S- as evidenced by verbalization of Appears weak: • pain and facial patient can not grimace of 10/10 perform ADL Facial grimace of • 10/10 restlessness • • VS taken as: T:36.2oC RR:28cpm PR:98bpm BP: 13O/9OmmHg • shows guarding behavior • irritable at times
Scientific Background
Bone fracture
Objectives Date: June 11, 2O1O Time: 8am Shift: 6-1OAM
Nursing Interventions Independent: >respond immediately to complaint of the patient
Rationale
Tissue trauma
activation of pain receptors
send signal to the brain
perception of pain
After 20-30 minutes of rendering nursing interventions and health teachings, the patient will verbalizes relief from pain.
>provide rest periods to facilitate comfort, sleep and relaxation Dependent >administration of analgesics as prescribed
>application of heat or col d c om pre ss as ordered
prompt responses to complaints may result in decreased anxiety in patient
Fatigue on the patient may exaggerate on the pain he experienced
To relieve pain
Hot moist compress have penetrating effect. Cold compress promote some numbing thereby promoting comfort
Evaluation Date: June 11,2O1O
Shift: 6-1OAM Goal partially met as evidenced by facial grimace of 6/10
IX. DRUG STUDY NAME OF DRUG
ORDERED DOSE
MECHANISM OF ACTION
PARACETAMO L
5Omg 1tab every 4 hours
Reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating which helps dissipate heat.
INDICATIONS
•
•
CONTRAINDICATIONS
SIDE EFFECTS
> Allergy to CNS: headache Common cold, flu CV: chest pain, dyspnea ot he r v ir al an d acetaminophen GI: hepatic toxicity and failure bacterial infections with pain and fever > use cautiously GU: impotence with impaired Hematologic: hepatic function, met hemo gl obi ne mi a – Analgesiccyanosis, hemolytic antipyretic in chronic anemia,.leukopenia, patients with aspirin alcoholism, and pancytopenia allergy , hemostatic pregnancy lactation Hypersensitivity: Rash, fever disturbances, bleeding, upper GI di sea se , g ou ty arthritis
NURSING RESPONSIBILITY
•
Arthritis and rheumatoid disorders involving musculoskeletal pain – but lacks clinically significant antirheumatic and anti-inflammatory effects.
Practice the 1O R’s of drug administration. Avoid using multiple preparations containing acetaminophen. Carefully check any OTC drugs Do not exceed recommended dose Take only for complaints indicated for fever. It is not an anti inflammatory agent.
CELECOXIB
2OOmg 1capsule BID
Analgesic and anti-inflammatory activities related to inhibition of the COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; does not affect the COX-1 enzyme, which protects the lining of the GIT and has blood clotting and renal functions
•
•
Management of acute pain Treatment of signs and symptoms of rheumatoid arthritis and osteoarthritis
>Contraindicated CNS: h/a, tiredness, fatigue, with allergies to dizziness, somnolence, sulfonamides, insomnia, tinnitus, celecoxib, ophthalmologic effects NSAIDsor CV: MI, CVA aspirin; Dermatologic: rash, alopecia, significant renal pruritus, sweating, dry mucous impairment. membranes, stomatitis GI: dyspepsia, nausea, GI bleeding, abdominal pain, >Use cautiously Flatulence with impaired Hematologic: Neutropenia, hearing, hepatic leukopenia, pancytopenia, and CV thrombocytopenia conditions
Practice the 1O R’s of drug administration. Administer drug with food or after meals if GI upset occurs. Establish safety measures if CNS or visual disturbances occur. Take only the prescribed dosage. Report any side effects.