St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME: X.M.
AGE: 37years old
Dr.: Dr.A.
CC: V.A. NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Fractures occur when GENERAL: INDEPENDENT:
“budlayan ako Impaired physical the bone is subjected After 8 hours of After 8 hours of rendering
magtindug” as mobility, inability to stress greater that rendering appropriate appropriate nursing
verbalized by the to stand alone it can absorb. When nursing interventions interventions the patient was
patient related to skeletal the bone is broken, the patient will be able able to:
impairment to adjacent structures to:
facture of the 2nd are also affected, 1. Demonstrate -assist patient to do -to improve muscle 1. Demonstrate
metatarsal at left resulting in soft tissue increasing function active ROM exercises on strength and joint increasing function of
foot and left edema, hemorrhage of the extremities the lower extremities mobility. the extremities.
OBJECTIVE shoulder into the muscles and (GULANICK &
-received patient lying joints, joints MYERS:2007, p. 127)
on bed, awake, dislocations, ruptured 2. Regain or maintain
coherent, & responsive: ten-dons, severed mobility at the highest
nerves, and damaged possible level.
-grimace face noted blood vessels. Body
organs maybe injured DEPENDENT:
- limited ROM by the force that -administer analgesics -in order for the muscle 3. Verbalize
caused the fracture such as Tramadol to be more relax and understanding of the
V/S fragments. After a (Tramal) as prescribed relieve the pain situation /risk factors,
• BP: 120/80mmHg fracture, the by the physician. (GULANICK & individual therapeutic
• T : 37°C extremities cannot MYERS:2007, p. 127) regimen and safety.
• PR : 77 bpm function properly COLLABORATIVE:
• RR : 19cpm because normal - consult with physical or -to develop individual -Goal was partially met
 02sat:97 functions of muscle occupational therapist exercise or mobility
depend on the as indicated. program and identify
integrity of the bones appropriate adjunctive
which they are devices.
attached. (Gulanick (GULANICK &
&Myers: 2007, p.126) MYERS:2007, p. 129)
INDEPENDENT
2. Regain or maintain -assess degree of -patient may be
mobility at the mobility produced by restricted by self-view
highest possible injury or treatment and or self- perception out
level note patient’s of proportion with
perception of immobility actual physical
3. Verbalize limitations requiring
understanding of interventions to
the situation /risk promote progress
factors, individual toward wellness.
therapeutic (GULANICK &
regimen and safety MYERS:2007, p. 127)
measures