DATA/CUES NURSING SCIENTIFIC GOAL/OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS BACKGROUND INTERVENTIONS

Subjective: Acute Pain Vehicular accident Short Term: Independent: Short Term:
“Sumasakit at secondary to ↓ After 4 hours of nursing Position the client in a To be more comfortable. After 4 hours of
kumikirot ang paa vehicular Collision interventions, the comfortable position. nursing
ko, parang accident ↓ patient will be able to: interventions, the
namamaga” as evidenced by Bone trauma  Verbalize Encourage ambulation To divert attention on goal is met as
verbalized by the pain scale 7/10, ↓ minimized or even minimal pain and increases evidenced by the
patient. facial grimace, Femoral neck feeling of pain movement of circulation. patient being able
irritability, fracture in left leg with pain scale unaffected part. to:
Objective: guarding ↓ of 3/10 and  Verbalized
 Vital signs: behaviour, Nerve ending absence of Provide rest, sleep, To provide comfort. minimized
o Temp- weakness, skin excitability irritability, and relaxation. feeling of
36.9 C around the ↓ discomfort, pain with
o PR- 89 affected area is Pain fiber irritability weakness, Instruct family To provide rest and pain scale
bpm red and ↓ guarding member to eliminate comfort. of 3/10 and
o RR- swollen, Muscle spasm behaviour and any positive stressor absence of
20 restlessness ↓ facial grimace. or discomfort. irritability,
cpm Acute pain   Verbalize discomfort
o BP- methods that Instruct and Help to promote and facial
130/90 provide relief demonstrate of how to circulation, relaxation of grimace.
mmHg https://www.emedicine do a deep breathing muscles. (08/30/21 –
health.com/bone_fract Long Term: exercise. 3PM)
o O2 sat ure_broken_bone/artic After 2 days of nursing
- 97%  Verbalized
le_em.htm#:~:text=Th To lessen fatigue that
 Pain scale interventions, the methods
e%20integrity%20of may add discomfort to
patient will be able to: Keep environment that provide
7/10 with 10 %20the%20bone
 Demonstrate use calm and quiet and the client relief
as the highest %20has%20been
%20damaged of relaxation promote adequate rest (08/30/21 –
score
%2C,irritated skills & periods. 3PM)
 Facial To avoid inflicting pain
grimace %20when%20the diversional
%20bone%20is activities such Handle extremity with on the extremity Long Term:
 Irritability %20broken%20or great care and
as deep After 2 days of
 Guarding %20bruised. breathing gentleness. nursing
behaviour exercises, interventions, the
 Weakness guided imagery, Dependent: To alleviate pain. goal is met as
 Skin around and provision of Administer prescribed evidenced by the
the affected distractions such pain medication as patient has been
aresa is red as radio or TV. ordered able to:
and swollen  Have decreased  Demonstrat
 restlessness inflammation e use of
and swelling relaxation
skills &
diversional
activities
such as
deep
breathing
exercises,
guided
imagery,
and
provision of
distractions
such as
radio or TV.
(09/01/21 –
3PM)
 Have
decreased
inflammatio
n and
swelling.
(09/01/21 –
3PM)