Nursing Care Plan

Nursing Diagnosis Acute pain related to soft tissue trauma and open fracture as manifested by grimacing face, guarding behaviour on left forearm (radius and ulna), pain scale of 7/10, reluctance in moving and verbalization of nasakit detoy naitama nga immak. Nursing Inference A fracture is a break in one or more cortices of a bone. Fracture occurs when the bone is subjected to stress greater than what it can absorb. The open fracture in the left forearm of the patient was brought by fall accident. The breakage in the continuity of the bone and damaged of its surrounding soft tissues stimulates inflammatory process wherein chemical mediators such as prostaglandin which irritates the cells causing pain, histamine, bradykinin and serotonin are also released. As a result of this, capillary permeability increases leading to swelling. If there is swelling, there is compression of nerve endings where pain receptors are located, thus pain sensations occurs. Moreover, open fracture can result to severed nerves and damaged blood vessels ,thus more pain felt by the client.

Nursing Goal After 2 to 4 of rendering effective nursing interventions the pain felt by the patient will be lessened as will be manifested by pain intensity of 2/10, absence of grimacing face and guarding behaviour on left forearm, more relax in appearance and a verbalization of Han unay nasakit detoy ima kon

Nursing Interventions: 1. Administer stat analgesics as prescribed by physician. Rationale: to alleviate the pain

2. Promote the use of diversional activities. Rationale: The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeuticeffects of pain relief medications. These divert the attention of the patient from the pain, thus, reducing its sensation. 3. Ask patient to do deep breathing exercises. Rationale: deep breatjing exercises promote relaxation and reduce anxiety which may aggravate sensation of pain. 4. Create a quiet, nondisruptive environment with dim lights and comfortable temperature when possible. Rationale: Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction.

1. Administer stat analgesics as ordered. Rationale: To relieve pain 2. Handle the affected area gently. Rationale: Movement of bone fragments is painful, adequate support reduces soft tissue tension and lesser pain. 3. Maintain immobilization of the affected parts by means of positioning the client comfortably on bed and avoid unnecessary movements on the affected area. Rationale: Relieves pain and prevents bone displacement and extension of tissue injury. 4. Monitor for relief of pain. Rationale: To determine if there is improvement. 5. Provide a quiet, nondisruptive environment and comfortable temperature when possible. Rationale: Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction.

6. Promote health teachings such as: y Encourage patient to eat foods rich in vitamins, minerals and protein such as lean meat, beans, fresh fruits and vegetables. y Do deep breathing exercises.

Rationale: Deep breathing exercises promote relaxation and reduce anxiety which may aggravate sensation of pain.

Use diversional activities such as reading magazines or use music therapy. Rationale: The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic ffects of pain relief medications. These divert the attention of the patient from the pain, thus, reducing its sensation

Nursing Evaluation After 2 to 4 of rendering effective nursing interventions the pain felt by the patient was lessened as manifested by pain intensity of 2/10, absence of grimacing face and guarding behaviour, more relax in appearance and a verbalization of Han unay nasakit detoy ima kon