ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

“Hindi ko po Partially impaired Goal: After 4 Assess for To maintain After the
maigalaw physical mobility hours of nursing correct good body nursing
yung paa related to intervention, position of alignment intervention,
kasi may musculoskeletal the patient will traction and when the patient was
nakalagay” disorder be able to alignment of mechanical able to maintain
as (pathologic maintain bones devices are position of
verbalized fracture, distal position of used function and
by the 3rd femur) and function with exerted maximum
This prevents
patient external device maximum mobility Maintain mobility within
footdrop and
(balance skeletal within the limbs in the therapeutic
excessive
traction) therapeutic functional limits of
plantar
Objective limits of alignment traction.
flexion
data traction. (with
pillows,
-Noted
sandbags,
deformity of
etc.).
thigh due to
Support feet
pathologic
in
fracture
dorsiflexed
-Presence of position
restrictive
Allow patient To increase
device
to perform patient’s
(balanced
tasks at his recovery and
skeletal
own rate. increase his
traction)
Encourage self-esteem.
-Insertion independent
of steinmann activity as
pin able as safe.
Encourage use Strengthen
of trapeze shoulders an
arm muscles
necessary for
safe
positioning
and
mobilization
 NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Objective: Risk for Patient will  Assess sign  Fever may indicate Patient was free
infection free from any and symptoms infection from any signs
first
signs and of infection and symptoms of
degree
symptoms of especially  It serves as a infections as
benign
infections as temperature first line of manifested by
tumor
manifested by  Emphasize the defense against absence of fever
absence of fever importance of infection
hand washing
technique.  Wet area can be
 Keep area lodge area of
around wound bacteria
clean and dry.
 Premature
discontinuation of
 Emphasized treatment when
necessity of client begins to
taking feel well may
antibiotics as result in return of
ordered. infection.