Professional Documents
Culture Documents
subjective data
patients said pain in the right foot
objective data
p: 1. more pain when moving
2. the current position of the right leg straight in line with the body
Q: pain
R: right leg
S: scale 8
Q: continue
priority diagnosis
1. based on post-trauma acute pain with fractures
2. impaired physical mobility based fractures of cruris
3. resti based wound infection post-op stitches
PLANNING
NOC
1. pain management
2. self-care aids
3. surveillance skin
ACTIVITIES
3. - Identification of the source of latex that is exposed by a patient either at home or in the
workplace
- Examine the patient and family knowledge about the sources of latex
- Examine the knowledge of sensitization and allergic reactions
- Recommended for self-treatment if you do not have an allergic reaction is suspected
- Psien and teach families about the risk factors of latex allergy
IMPLEMENTATION
3. monitor for signs and symptoms of infection include vital signs and postoperative state
response
implementation
response
1. s: patient said it is willing to do deep breathing relaxation
o: the patient looks relaxed
EVALUATION