Patient: Mr.

R Diagnosis: Fractured Tibia, Fibula Open Type II Complete, Comminuted

25 M
 Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Basis
Subjective Chronic pain > A break in the Goal: Independent: > Identifying the After 4 hours of
Data: related to bone is known as After 4 hours of > Assess specific cause nurse- patient
a fracture. There
Patient swelling and nurse- patient symmetry, guides design of interaction, the
are two main
verbalized, tenderness of types of fracture: interaction, the strength, optimal treatment patient was
“Ngul-ngul the fractured the simple (close) patient will be degree of plan. able to properly
akong tiil”. lower leg, and and compound able to use mobility. >This optimizes use assistive
inability to (open). The simple assistive > Position circulation to all devices as
Objective move fracture is a break equipment patient in tissues and provided.
in the bone that
Data: purposefully in properly, show proper body relieves pressure. Patient was also
does not pierce
RR= 27 cpm the the skin or cause progress in alignment. >Exercise able to progress
T°= 36.6°C environment severe damage to mobility on bed, > Encourage promotes in mobilization
BP= 100/70 including surrounding and be able to isometric increased venous through
mmHg mobility, tissues. In the transfer without exercises when return, prevents exercises and
PR= 76 bpm transfers, and compound feeling any indicated. stiffness, and was slowly able
fracture, the skin
> Patient is ambulation pain. > Teach proper maintains muscle to move himself
and tissues are
unable to move secondary to broken through. A use of assistive strength and up in bed
lower leg. fractured tibia, fracture may also Planned device such as endurance. without pain.
> Skin is fibula open be complete, Actions: crutches. >Proper use of Patient was also
discolored type II dividing the bone > Maintain or > Provide wheelchairs, able to properly
> Swelling of complete, into two or more increase progressive canes, transfer groom himself
skin noted comminuted 25 separate pieces. It strength and mobilization. bars, and other without help.
may be also
> Grimacing of M. incomplete or endurance of assistance can Patient was
patient’s face partial. In a fractured lower Dependent: promote activity able to take the
was noted comminuted leg. >Passive/active and reduce danger prescribed
> Patient is not fracture, the bone > Make sure no ROM exercises of falls. medication.
properly is broken into little complications as ordered by >The longer the
groomed pieces at the point will develop physician to the patient remains
of fracture.
(Reader’s Digest
during injured body part. immobile the
Medical immobilization. > Administer greater the risk of
Family Health
Diagnosis: Guide and Medical > Demonstrate proper complications.
Fractured Tibia, Encyclopedia) the proper use medication as (www1.us.elsevier
Fibula Open > Lower leg of assistive prescribed by health.com)
Type II fractures include devices. the physician.
the fractures of
Complete, the tibia and
Comminuted 25 Expected Collaborative:
fibula. Of these
Name of Student: Bongon, Claudine Y. BSN1-N1