CUES NURSING SCIENTIFIC GOAL & NURSING RATIONALE EVALUATION

DIAGNOSIS BASIS OUTCOME ACTIONS &

CRITERIA NURSING
ORDERS
Subjective Impaired Fractures occur After 8 hours of After 8 hours of
cues: physical when the bone is rendering appropriate rendering
-“ sakit akong mobility, subjected to stress nursing interventions appropriate
luyo ug wala inability to stand greater that it can the patient will be nursing
nga tiil” as alone related to absorb. When the able to: interventions the
verbalized by skeletal bone is broken, Independent patient was able:
the patient. impairment to adjacent structures 1. Demonstrate - assist patient to -to improve
facture of the left are also affected, increasing do active ROM muscle 1.Demonstrate
Objective femoral neck resulting in soft function of exercises on the strength and increasing function
cues: tissue edema, the lower extremities. joint mobility. of the extremities.
-received hemorrhage into extremities. (GULANICK
patient lying the muscles and & MYERS: 2.Regain or
on bed, awake, joints, joints 2007, p. 127) maintain mobility
coherent, & dislocations, Dependent at the highest
responsive. ruptured ten-dons, -administer -in order for possible level.
severed nerves, analgesics such as the muscle to
-IVF of 1 L # and damaged blood Tramadol (Tramal) be more relax 3. Verbalize
21 PLR with vessels. Body as prescribed by and relieves understanding of
remaining 270 organs maybe the physician. the pain the situation /risk
mL @ 30 injured by the (GULANICK factors, individual
gtts/min. force that caused & MYERS: therapeutic
infusing well the fracture 2007, p. 127) regimen and
@ right arm. fragments. After a Collaborative safety.
fracture, the - consult with -to develop
- grimace face extremities cannot physical or individual -Goal was met
noted function properly occupational exercise or
because normal therapist as mobility
- limited ROM functions of indicated. program and
muscle depend on identify
the integrity of the appropriate
bones which they adjunctive
-v/s are attached. devices.
 BP: (Gulanick & (GULANICK
130/80 Myers: 2007, p. & MYERS:
mmHg 126) 2007, p. 129)
 T: 2. Regain or Independent
38.2°C maintain -assess degree of -patient may
 P : 75 mobility at mobility produced be restricted
bpm the highest by injury or by self-view
 R : 20 possible treatment and note or self-
cpm level. patient’s perception out
perception of of proportion
immobility. with actual
physical
limitations
requiring
interventions
to promote
progress
toward
wellness.
(GULANICK
& MYERS:
3. Verbalize 2007, p. 127)
understanding
of the
situation /risk
factors,
individual
therapeutic
regimen and
safety
measures.
 NURSING SCIENTIFIC BASIS GOAL & NURSING
CUES DIAGNOSIS OUTCOME ACTIONS & RATIONALE EVALUATION
CRITERIA NURSING
ORDERS
Subjective Alteration in Pain is a typical sensory After 8 hours of After 8 hours of
cues: comfort : Acute experience that may be rendering rendering
-“ sakit akong Pain related to described as the appropriate nursing appropriate
luyo ug wala tissue trauma 2° unpleasant awareness of intervention, the nursing
nga tiil” as to MVA a noxious stimulus or patient will be able intervention, the
verbalized by bodily harm. to reduced pain patient was able
the patient. Individuals experience from 8 to 4 with 10 to have reduction
pain by various daily as the most painful. of pain from 8 to
Objective hurts and aches, and Independent 4 with 10 as the
cues: occasionally through 1. The patient - perform proper - appropriate most painful.
-received more serious injuries or will verbalize nursing measures will
patient lying illnesses. Pain is reduction of interventions and be 1. The patient
on bed, defined scientifically as pain from a appropriate implemented will verbalize
awake, unpleasant sensory and pain scale of 4 procedures to to prevent reduction of
coherent, & emotional experience in a 0-10 scale alleviate pain. infections and pain from a
responsive. associated with actual with 10 as the complications. pain scale of
or potential tissue most painful. -use non- - use of non- 4 in a 0-10
- diaphoresis damage, or described in pharmacologic pharmacologic scale with 10
terms of such damage. interventions for methods will as the most
- pain scale of Pain of any type is the relieving pain embrace the painful.
8/10, as of 0 most frequent reason (eg. Relaxation) results of pain 2. Patient will
is no pian and why people tend to seek reliever. Gate demonstrate
10 is the most medical consultation. It control theory ways to
painful is a major symptom in states that reduce pain.
many medical cutaneous
-guarding conditions, significantly stimulation 3. The patient
behavior interfering with a closes the pain will
person’s quality of life pathways. appreciate the
- T : 38.2°C and general functioning. (BARE & care rendered.
Diagnosis is based on SMELTZER,
characterizing pain in 2004: 1140) - Goal was met
various ways, according Dependent
to duration, intensity, --administer -in order for
O – occurs type (dull, burning or analgesics such as the muscle to
when moving stabbing), source, or Tramadol be more relax
L – on his left location in body. (Tramal) as and relieves
leg Usually, pain stops prescribed by the the pain
D– without treatment or physician. (GULANICK
approximately responds to simple & MYERS:
1 min. measures such as 2007, p. 127)
C – gnawing resting or taking an
pain analgesic, and it is then
A – frequent called acute pain. But it Independent
moving may become intractable 2. Patient will - instruct patient -diverts
R – rest and develop into a demonstrate to use relaxation attention and
T – Tramadol condition called chronic ways to reduce exercises such as may enhance
(Tramal) pain, in which pain is pain. focused coping
no longer considered a breathing, abilities.
symptom but an illness commercial or (DOENGES,
by itself. The study of individualized 2002:368)
pain has it recent years tapes.
attracted many different
fields such as Dependent
pharmacology, -provide -promotes
neurobiology, nursing individualized active, not
sciences, dentistry, physical therapy passive role.
physiotherapy, and or exercise (DOENGES,
psychology. Pain program that can 2002: 369)
medicine is a separate be continued by
subspecialty figuring the client when
under some medical discharged.
specialties like
anesthesiology, Collaborative
physiatry, neurology, -encourage -bed rests
and psychiatry. Pain is patient to have decreases
part of the body’s adequate bed rest body
defense system, periods. metabolism
triggering a reflex and thus
reaction to retract from reduces
a painful stimulus, and muscle
helps adjust behavior to tension.
increase avoidance of (BARE &
that particular harmful SMELTZER,
stimulation in the 2004: 1140)
future. Given its Independent
significance, physical 3. The patient -establish a - Establish a
pain is also linked to will appreciate specific time to trusting
various cultural, the care talk with patient relationship
religious, philosophical, rendered. about pain and its that
or social issues. psychological and encompasses
(http://en.wikipedia.org) emotional effects. patient’s
physiological,
emotional,
social, sexual,
and financial
concerns.
(SPARKS &
TAYLOR,
2005: 227)
Dependent
-accept client’s - Pain is a
description of subjective
pain. experience
and cannot be
felt by others.
(DOENGES,
2002: 367)
Collaborative
-work closely - to achieve
with staff and pain
patient’s family. management
goals and
maximize
patient’s
cooperation.
(SPARKS &
TAYLOR, 2005:
227)
 NURSING SCIENTIFIC BASIS GOAL & NURSING
CUES DIAGNOSIS OUTCOME ACTIONS & RATIONALE EVALUATION
CRITERIA NURSING
ORDERS
Subjective
cues:
-“lisod man
ilihok akong
lawas” as
verbalized by
the patient.