Submitted by: LEADY JOY MORBO Subject: NCMA113

Level & Section: BSN 1YC-25 Date Submitted: 06- 27-2024

NURSING CARE PLAN

Patient’s Name: ALLIANA DE GUZMAN Care plan by: L. Morbo, SN
Patient's Age: 26 Date Initiated: 06-27-2024
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Acute pain related to Short Term: Independent: Independent: Short Term:
“My ankle hurts so broken bone of the Within 4 hours of 1. Monitor vital signs 1. No significant Within 4 hours of
much. I can’t bear it ankle as evidenced nursing intervention, q 4 hours until stable; changes in vital signs nursing intervention,
anymore.”, as by the patient will be 2. Observe nonverbal indicates ineffective the patient:
verbalized by the facial expression of able to: cues and pain intervention to the ➢ Verbalized
patient. pain, pain scale of 9 ➢ Verbalize behaviors; patient; controlled or
out of 10, swelling, controlled or 3. Maintain patient’s 2. Observations may relief from
Objective: bruising, and relief from injured ankle not be congruent with pain;
-facial expression of deformity at the injury pain; elevated using firm verbal reports; ➢ Preserved
pain site. ➢ Preserve pillows; 3. To reduce swelling stable vital
(+) swelling and stable vital 4. Perform pain and pain and promote signs.
bruising signs. assessment each circulation; ➢ Followed
(+) deformity around Inference: Fracture ➢ Follow time pain occurs or 4. To demonstrate prescribed
the ankle is a crack or break in prescribed after administering improvement in pharmacologic
-examination a bone, caused by pharmacolog analgesics; status; al regimen;
revealed a fracture either a trauma or an ical regimen; 5. Provide a quiet 5. To help in ➢ Utilized
underlying condition. ➢ Utilize environment or self-management of nonpharmacol
VS taken as A fracture may nonpharmac comfortable position; pain and stress; ogic pain relief
follows: manifest unstable v/s, ologic pain 6. Encourage rest 6. To promote faster measures;
Temp: 37.5 C diaphoresis, severe relief and sleep; healing processes —-GOALS MET—--
PR: 105 pain, limited ROM, measures. 7. Apply cold packs and deviate from the
RR: 22 edema, bruising, or to the injury site q 2 pain; Long Term:
BP: 116/70 bone deformity. Long Term: hours. After a month of
 Submitted by: LEADY JOY MORBO Subject: NCMA113
Level & Section: BSN 1YC-25 Date Submitted: 06- 27-2024

Pain scale of 9 out of (Fracture: Causes, After a month of 7. To reduce swelling nursing interventions,
10 Symptoms, nursing Dependent: and pain the patient:
Treatments, and interventions, the 1. Provide analgesics ➢ Was free of
Cost, 2023). patient will/ will be: as ordered by the Dependent: any pain from
➢ Free of any physician. 1. To maintain an injured ankle;
pain from “acceptable” level of and
injured Collaborative: pain. ➢ Demonstrated
ankle; and 1. Refer to a physical moderate
➢ Demonstrate therapist or exercise Collaborative: execution of
moderate program that can be 1. Promotes active, activities of
execution of continued by the rather than passive, daily living;
activities of client after discharge. role and enhances —GOALS MET—-
daily living. sense of control.

Case scenario: Alliana De Guzman is a 26 year old woman who was brought into the A&E. Her face expressed pain and complained, “My
ankle hurts so much. I can't bear it anymore”. She suffered a trauma to her ankle in which she fell down in an under construction road hole. Her
examination revealed a fracture with signs of swelling, bruising and deformity around the ankle. Her temp is 37.5°C, Pulse is 105, Respirations
are 22, B/P is 116/70.