Assessment Subjective:

Diagnosis Acute pain related to Open Reduction Internal Fixation (ORIF) on left femur

Objective: V/S as Follows: BP : 120/80 mmHg PR : 72 bpm RR : 24 cpm Temp. : 36.8 C

Scientific rationale Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury as lasting from seconds to 6 months. In cases of fracture, pain is continuous and increasing in severity until bone fragments are immobilized. In this type of fracture, the main medical management is open reduction with internal fixation (ORIF), wherein the fracture fragments are reduced and internal fixation devices are used to hold the bone fragment in position until solid bone healing occurs.

Planning After 8 hours of nursing intervention, the patient will: a) Verbalizes minimized or controlled feeling of pain b) Verbalizes methods that provide relief c) Demonstrate use of relaxation skills and diversional activities

Implementation Vital signs were monitored q 4 hours until stable and dressing was checked.

Adjusted constricting bandage and advised to elevate Right leg

Instructed to do activities such as deep breathing exercise, coughing exercise and sitting exercises.

Noted to avoid weight bearing until allowed.

Scientific rationale Alterations from normal may be signs of infection. Moistened dressings are favorable site for microorganism to culture. This is to prevent diminished circulatory and nerve function and control swelling of the site. To reduce swelling and prevent stiffness the stated activities must be done. Decreased lung capacity and decreased cough efficiency are predisposing factors to respiratory infections. To prevent from complications

Evaluation After 8 hours of nursing intervention the pain is reduced controlled to a tolerable extent as verbalized. Relieving methods and relaxation techniques are understood and demonstrated.

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 Encouraged to void freely.

Enough rest and sleep was also advised.

Intake of pain reliever and antibacterial

on the incision site, activities that may extend the cut must be avoided. This is advised in order to prevent constipation and fecal impaction. This promotes healing by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration. NSAID is an example to relieve severe to moderate pain

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Assessment Subjective: Hindi ko maigalaw ung binti ko , as verbalized by the patient

Diagnosis Impaired physical mobility related to Open Reduction Internal Fixation

Objective: limited range of motion slowed movement limited ability to perform gross and fine motor with ORIF on Right leg V/S as Follows: BP : 120/80 mmHg PR : 72 bpm RR : 24 cpm Temp. : 36.8 C

Scientific rationale Open reduction internal fixation is a method of surgically repairing a fractured bone. Generally, this involves either the use of plates and screws or an intramedullary (IM) rod to stabilize the bone. And due to the ORIF the patient is restricted to move.

Planning At the end 6hours of nurse-patient interaction and intervention, the patient will: a.)Verbalize understanding of the situation and individual treatment regimen and safety measures. b.)Participate in ADLs and desired activities c.) Maintain position of function and skin integrity as evidenced by absence of decubitus ulcers d.) Maintain and increase strength and function of affected part.

Implementation Determine diagnosis that contributes to immobility. Note situations such as fractures Determine the degree of immobility in relation to suggested scale Determine presence of complications related to immobility(pneum onia, elimination problems, decubitus) Assist client reposition self on a regular schedule

Scientific rationale To identify contributing factors Because it may restrict movement To assess functional mobility To assess presence of complications

Evaluation After 6hrs. of nursepatient interaction and intervention, the patient has: a.) Verbalized understanding of the situation and individual treatment regimen and safety measures. b.) Participated in ADLs and desired activities c.) Maintained position of function and skin integrity as evidenced by absence of decubitus ulcers d.) Maintained and increased strength and function of affected part.

Support affected body part using pillows.

to promote optimum level of function and prevent complication To maintain position and function and reduce risk of pressure ulcers. It promote wellbeing and maximizes energy production

Encourage adequate intake of fluids/nutritious foods

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Assessment Subjective: as verbalized by the patient

Diagnosis Risk for infection related to wound secondary to fracture

Scientific rationale Trauma (Vehicular accident) Fracture of the left leg Bleeding from damaged ends of bone and surrounding tissue Broken skin(wound) Risk for infection

Planning After 6 hours nursepatient interaction and intervention the patient will: a) Identify interventions to prevent/redu ce risk of infection b) Achieve timely wound healing; be free of purulent drainage or erythema; c) Be afebrile as evidenced by the normal V/S

Implementation Note risk factor for occurrence of infection Observe for localized signs of infection. Stress proper handhygiene by all caregivers bet. Therapies/clients Recommend routine or body shower/scrub when indicated Change surgical or other wound dressings, as indicated, using proper technique for changing or disposing of contaminated materials Review individual nutritional needs,

Scientific rationale To assess causative/contrib uting factors To assess for infected sites A first line defense against healthcareassociated infection To reduce bacterial colonization To prevent infection

Evaluation After 6hr nurse-patient interaction and intervention the patient has: a) Identified interventions to prevent/reduce risk of infection b) Achieved timely wound healing; be free of purulent drainage or erythema; c) Been afebrile as evidenced by the normal V/S

Objective: Open wound ORIF on left Femur Immobility

V/S as Follows: BP : 120/80 mmHg PR : 72 bpm RR : 24 cpm Temp. : 36.8 C

To promote wellness.

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