PRESENTATION

EVRMC
ORTHOPEDIC
WARD
FEBRUARY 24, 2016
9:00AM-12:00NN
Traumatic
Brain
Injury
Medical Diagnosis :
Traumatic Brain Injury
Psychiatric Diagnosis :
To be considered Neurocognitive
Disorder due to Traumatic Brain Injury
with Behavioural Disturbances
Traumatic Brain Injury from alleged
MVC
TBI is generally the result of a sudden,
violent blow or jolt to the head. The brain is
launched into a collision course with the
inside of the skull, resulting in possible
bruising of the brain, tearing of nerve fibers
and bleeding.
TBI severity varies enormously depending
on which part of the brain is affected,
whether it occurred in a specific location or
 Epidemiology
TBI is a leading cause of death and disability
around the globe and presents a major
worldwide social, economic, and health
problem. It is the number one cause of
coma. It plays the leading role in disability
due to trauma, and is the leading cause of
brain damage in children and young adults .
 Epidemiology
Findings on the frequency of each level
of severity vary based on the
definitions and methods used in
studies. A World Health Organization
study estimated that between 70 and
90% of head injuries that receive
treatment are mild, and a US study
found that moderate and severe
NURSING
ASSESME
 Patients Profile
Name: Gonzaga, Gerardo
Age: 61 years old Sex: Male
Occupation: Carpenter
Civil Status: Married
Religion: Roman Catholic
Address: Brgy. Hibucawan,
Jaro, Leyte
Nationality: Filipino
No. of Children: 4
Work of Wife: Housewife
Date of Admission: February
13, 2017
Time of admission: 7:00 PM
Admitting Physician: Dr. Jay
Stephen Cantay
Admitting Diagnosis: Traumatic
Brain Injury from altered MVA
Source of Data: Patient and
HEALTH
HISTORY
 PRESENT HEALTH
HISTORY
He was going home from
work when another motorcycle
bumped on his rear side. That
one vehicle came into contact
with another. According to the
patient, his head bumped into
the road cement.
He was immediately brought in
to Jaro Municipal Health Office
and was referred to Eastern
Visayas Regional Medical Center
for further evaluation at 7:00 PM
last February 13, 2017 and was
examined by Dr. Jay Stephen
Cantay, hence admission.
PAST MEDICAL HISTORY
Patient claimed that he was
hospitalized at Carigara District
Hospital due to hypertension last
December 2016. Before admission,
he added that he was already been
prescribed with Metropolol and
took it once a day. He confirmed
that no other hospitalization was
FAMILY HEALTH HISTORY
Patient claimed of heredo-
familial disease of asthma on
his maternal side and
hypertension on his paternal
side. No other known heredo-
familial disease noted.
 GORDONS
FUNCTIONAL
HEALTH PATTERN
HEALTH PERCEPTION-HEALTH
MANAGEMENT PATTERN

Before admission, patient G

describes his health as okay man la,
nakakatrabaho man gihap bis amo na
it akon edad as verbalized.
According to him, he eats three
times a day in order for him to get
rid and to prevent diseases.
 During admission,
patient describes his
health as alkanse na ha
kinabuhi kay waray na kita
dong. He claimed that
there were some
medications that they
 He stated that due to his
condition, it would be hard for him
to take care of himself and children
as well. Patient added that he had
complains of vision deficit but not
able to seek proper eye care but
instead he just bought an
eyeglasses, gilid-gilid ko man la
gipalit dong as verbalized.
NUTRITIONAL-METABOLIC
PATTERN
Before admission, patient
GG eats three times a day
and snacks twice a day.
Patient consumed 1-2 litre
of water per day. He stated
that his appetite was good
and he has no food
 Patient claimed that he does
not take any supplemental
vitamins prior to admission.

Currently, Patient was

prescribed to Diet as Tolerated
but he claimed that his appetite
has changed.
ELIMINATION PATTERN
Before admission, patient GG
claimed that he defecates once a day
without experiencing discomforts
usually in the morning with a brown
colored stool and is well-formed. He
also stated that he voids three times
a day with yellow colored urine. No
pain when voiding as he claimed.
 During admission, patient
claimed that he defecates
once every two to three
days with a hard stool. He
also added that he voids via
catheter and does not feel
any urge to urinate.
SLEEP-REST PATTERN
Before admission, patient claimed that
he sometimes worked 7 days per week.
Patient verbalizes okay man la dong,
makapahuway man gihap ak. He rated
his tiredness as 5 out of 10. Patient also
added that he usually sleeps at 9 to 10
PM and wakes up 4:30 in the morning. He
does not use any sleeping aids and does
not have any difficulties when sleeping.
Currently, patient
experiences disturbed
sleeping pattern because
of some interruptions
such as giving
medications and noise in
the surroundings. He
ACTIVITY-EXERCISE PATTERN
Before admission, patient works
as a carpenter. ang mga baskog
man ang patrabahuon sa mga
lisud2x dong as verbalized by the
patient so he rated his tiredness
as 5 out of 10 with 10 the most
tiring. He stated that he can do his
activities of daily living.
During admission, he claimed that
his activities of daily living is
already limited due to his
condition and relies on his wife in
his self care. Patient verbalizes
that di man kaayo ko
makalihok2x dong. Makuri gihap
ngan maol-ol kung maglihok akon
tuda.
COGNITIVE-EXERCISE PATTERN

He claimed that he has some

complaints of difficulty concentrating
and reading on small letters. He
added that he does not seek proper
eye medical care yet bought an
eyeglasses, gilid-gilid ko man la
gipalit dong as patient verbalizes.
 Patient claimed that
when using the
eyeglasses, he
experienced headache.
Patient can speak and
understand Waray-waray,
Cebuano, Tagalog and a
SELF PERCEPTION PATTERN
Patient claimed that he is
concerned about the financial
sources for his hospital bills.
ako la an may trabaho ha amon
dong, mayda ako anak na pulis
pero bago paman la hiya naka
sulod as stated by the patient.
ROLE RELATIONSHIP PATTERN
Patient claimed that he is living
with his wife and four children. He
also added that he usually decides
for his family until the accident
happened.
During confinement, he is
accompanied by his wife and stays
with him most of the time.
SEXUALITY-RELATIONSHIP PATTERN
Patient GG claimed that he was
married at the age of 23. They
were married for 15 years and
got separated. Patient now has
a common-law-wife and they
have 4 children. They are now
living for almost 21 years.
COPING-STRESS MANAGEMENT
PATTERN
Patient claimed that his
mother died at the age of 93
last December 2016. He stated
that there is nothing he would
like to change in his self. He
also added that when he is
stressed, he usually seeks
VALUE-BELIEF SYSTEM PATTERN
Patient claimed that he is a Roman
Catholic. He stated that diri man ako
makasimba kada dominggo dong labi na
kung may trabaho pero mutuo ngan
nagsalig ako ha Ginoo, priority ko man
gihap it pagsimba. The patient also
added that there are no practices that
affect his hospitalization. He claimed that
a strong faith in God will accounts for his
fast progress.
 Body Part Patients Findings

Skin - Abrasion lesion observed on both wrist

- Abrasion lesion observed on left scapular area
- Abrasion lesion observed on lower left lumbar area
- Skin turgor of 3 sec

Nails -CRT of 3 sec

Head - Wound lesion observed in the left occipital area with 4 stitsches
- Tenderness noted

Eyes - Periorbital Hematoma noted on both eyes

- Subconjuctival haemorrhage on right eye noted

Chest - Lesion observed on left breast; nontender; with complaints of episodic tenderness

Legs - Open fracture of Tibia noted on left leg; tenderness noted

Date Diagnostic Normal Patients Significant Findings
Test Results Results
Feb. Hemoglobin 130180 120g/L Decreased in all anemias in
13, count g/L leukemia,
2017 and after hemorrhage
Hematocrit 42%52% 35 % Decreased in severe
count anemias, anemia of
pregnancy, acute massive
blood loss
Red Blood 4.66.2 4.23 Decreased in various
Cell Count 1012/L 1012/L anemias, pregnancy,
severe or prolonged
hemorrhage,
and with excessive fluid
intake
White blood 4.511 18.55 Increased in presence of
Cell Count 109/L infections
Date Diagnostic Significant
Test Findings
Feb. 15, 2017 Computed -Contusions,
Tomography Frontal and Left
cerebellum
-Left Occipital
Bone Fracture
-Minor
Hemosinus, Left
Maxillary
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
RISPERIDONE, THERAPEUTIC Schizophrenia, CNS: BEFORE:
2mg, 1tab Oral, CLASS: Irritability, parkinsonism, Obtained
Hours of sleep Antipsychotic including suicide attempt, baseline BP
aggression, somnolence, and monitored
self injury and agitation,
PHARMACOLOGIC temper anxiety, DURING:
CLASS: tantrums dizziness, fever, Advised to
Benzisozole associated impaired avoid alcohol
dermative with an concentration, while taking
autistic abnormal this drug

disorder. thinking, AFTER:
MECHANISM OF dreaming tremor,
ACTION: Advised
CONTRAINDICA fatigue, patient to
Blocks dopamine TION: depression
avoid alcohol
and 5h2
Hypersensitive CV: tachycardia, Provided O2
receptors in the orthostatic
brain. to drug and in when
breastfeeding hypotension, necessary
women peripheral Warned
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
GI: constipation, Monitored for
nausea, vomiting, S/S of overdose
abdominal pain, (Drowsiness,
anorexia, dry sedation,
mouth, increased tachycardia,
saliva, diarrhea, hpn, EPS,
GU: urinary seizures
incontinence, Instructed to do
increased DBE
urination, Encourage Oral
abnormal orgasm, hygiene
vaginal dryness Advised patient
Metabolic: weight high fiber diet
gain, Instructed
hyperglycemia , patient to
weight loss elevate feet if
Musculoskeletal: not
arthralgia, back contraindicated
pain, limb pain,
myalgia
Respiratory:
dyspnea, coughing,
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
DIAZEPAM, 5mg, 1 THERAPEUTIC -Anxiety CNS: drowsiness, BEFORE:
tablet/ day, oral, CLASS: -Muscle Spasm dysarthria, slurred -Monitored V/S and
hours of sleep Anxiolytic -Tetanus speech, tremor, BP
transient amnesia, -Assessed for
PHARMACOLOGIC CONTAINDICATION: fatigue, ataxia, hypersensitivity
CLASS: -Hypersensitive to headache, DURING:
Benzodiazepine drug or soya insomnia, -Warned patient to
protein paradoxical avoid activities that
MECHANISM OF -Experiencing anxiety, require alertness
ACTION: shock and coma hallucination,
-Instructed SO to
-Acute angle minor changes in
assist & provided
Probably potential closure glaucoma EEG pattern
the effects of -Caution in patient CV: CV collapse, safety to patient
GABA, depress the with liver or renal bradycardia, -Advised increased
CNS and supress impairment, hypotension fiber diet & avoid
the spread of depression, history EENT: diplopia, alcohol
seizure activity of substance abuse blurred vision AFTER:
GI: constipation, -Monitored for
diarrhea with rectal dizziness, ataxia,
pain mental state
GU: urinary changes
incontinence & -Instructed patient
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
CEFTRIAXONE, THERAPEUTIC -Perioperative GI: - Instructed patient
500mg , IVTT every CLASS: prevention pseudomembranou to report discomfort
24 hours (8am- Antibiotic -UTI, septicaemia, s colitis, diarrhea at IV site
8pm) skin structure HEMA: - Tell patient to
PHARMACOLOGIC infection Eosinophilia, report adverse
CLASS: thrombocytosis, reactions promptly
Third Generation CONTRAINDICATIO leukopenia - Educated and
Cephalosporin, N: SKIN: pain, informed about the
Pregnancy risk -Hypersensitive to induration, rash adverse reactions
category B dry or other OTHER:
- Tell patient to
cephalosporin hypersensitivity
notify prescriber if
MECHANISM OF -Cautiously in reactions,
ACTION: patient anaphylaxis having loose stools
Inhibits cell wall hypersensitive to - Assessed for pain
synthesis, penicillin - Administered
promoting osmotic -Cautiously in pain meds. As
instability, usually breast feeding prescribed by the
baactericidal women physician

 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
Mannitol 100ml THERAPEUTIC -To reduce CNS: seizures, BEFORE:
IVTT every 12 CLASS: intraocular or dizziness,
hours (8 am- 8pm) Diuretic intracranial headache, fever DURING:
pressure or CV: edema, -To relieve thirst,
PHARMACOLOGIC cerebral edema thrombophlebitis, give frequent
CLASS: -To prevent oliguria hypotension, mouth care or
Osmotic diuretic or acute renal hypertension, fluids
failure heart failure, -Emphasized
MECHANISM OF -Oliguria tachycardia, importance of
ACTION: vascular overload drinking only the
Increases osmotic CONTRAINDICATIO EENT: blurred amount of fluids
pressure N: vision, rhinitis ordered.
glomerular filtrate, -Hypersensitive to GI: thirst, dry
thus inhibiting drug mouth, nausea, AFTER:
tubular -Anuria, active vomiting, diarrhea -Monitored vital
reabsorption of intracranial GU: urine retention sign and intake and
H2O and bleeding, severe META: dehydration output
electrolytes. It dehydration, SKIN: local pain, -Instructed patient
elevates plasma metabolic edema urticaria to promptly report
osmolarity and OTHERS: thirst, adverse reactions
increased H2O flow chill and discomfort at
into extracellular I.V. site.
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
Ketorolac THERAPEUTIC Short term CNS: Headache, Renal
Tromethamine 10 CLASS: management of ain dizziness, impairment,
ml IVTT every 8 NSAID (up to 5days) insomnia, fatigue, Impaired
hours (8 am- 4pm- Ophthalmic: Relief tinnitus, hearing,
12 am) PHARMACOLOGIC of ocular itching ophthalmologic allergies,
CLASS: due to seasonal effects. hepatic,
NSAID conjunctivitis and DERMATOLOGIC: Skin color and
relief of Rash, pruritus, lesions,
THERAPEUTIC postoperative sweating, dry orientation,
ACTIONS: inflammation and mucous reflexes,
Anti inflammatory pain after cataract membranes, peripheral
and analgesics surgery. GI: Nausea, sensation,
activity; inhibits dyspepsia, GI pain, clotting times,
prostaglandins and CONTRAINDICATIO diarrhea, vomiting, CBC,
leukotriene NS: constipation, adventitious
synthesis. Contraindicated flatulence, hepatic sounds
with significant impairment. Be aware that
renal impairment, GU: Dysuria, renal patient may be
during labor and impairment at risk for CV
delivery , lactation; HEMATOLOGIC: events, GI
patients wearing Bleeding, bleeding, renal
soft contact lenses decreased Hgb and toxicity, monitor
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
active peptic ulcer Protect drug
disease or GI, vials from light.
bleeding; Administer every
hypersensitivity to 6 hours to
ketorolac; as maintain serum
prophylactic levels and
analgesics before control pain.
major surgery;
treatment of
perioperative pain
in CABG; suspected
or confirmed
cerebrovascular
bleeding;
hemorrhagic
diathesis,
incomplete
hemostasis, high
risk of bleeding;
use with
probenecid,
pentoxyphylline.
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
Ranitidine THERAPEUTIC Short term CNS: Headcahe, Instruct patient
Hydrochloride IVTT CLASS: treatment of malaise, dizziness, not to take new
25mg every 8 Antiulcer active duodenal insomnia, vertigo. medication w/o
hours (8am- 4pm- ulcer. CV: Tachycardia, consulting
12am) PHARMACOLOGIC Maintenance bradycardia physician
CLASS: therapy for DERMATOLOGIC: Instruct patient
Histamine 2 duodenal ulcer Rash, alopecia to take as
anatagonist at reduced GI: Constipation, directed and do
dosage. diarrhea, nausea, not increase
THERAPEUTIC Short term vomiting, dose
ACTIONS: treatment of abdominal Allow 1 hour
Competitively GERD. pain,hepatitis. between any
inhibits the action Short term GU: Impotence or other antacid
of histamine at the treatment and decreased libido and ranitidine
H2 receptors of the maintenance HEMATOLOGIC: Avoid excessive
parietal cells of the therapy of Leukopenis, alcohol
stomach, inhibiting active, benign granulocytopenia, Assess patient
basal gastric acid gastric ulcer. thrombocytopenia for epigastric or
secretion and Treatment and LOCAL: Pain at IM abdominal pain
gastric acid maintenance of site local burning and frank or
secretion that is healing of or itching at IV site occult blood in
stimulated by food, erosive OTHER: the stool,
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
CONTRAINDICATIO Inform patient
N: that it may
Contraindicated cause
with allergy to drowsiness or
ranitidine, dizziness
lactation. Inform patient
that increased
fluid and
fiberintake may
minimize
constipation
Advise patient to
report onset of
black, tarry
stools; fever,
sore throat;
diarrhea;
dizziness; rash;
confusion; or
hallucinations to
health care
professional
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
Dexamethasone THERAPEUTIC Hypercalcemia CNS: Seizures, Tell patient to
Sodium Sulphate CLASS: associated with vertigo, shake
IVTT 10mg every 8 Anti inflammatory cancer headaches, suspension well
hours (8am- 4pm- Cancer insomnia, mood before use.
12am) PHARMACOLOGIC chemotheraphy swings, depression, Teach patient
CLASS: induced psychosis, how to instill
Corticosteroid nausea and intracerebral drops. Advise
vomiting. haemorrhage, him to wash
MECHANISM OF Cerebral edema cataracts, hands before
ACTION: associated with glaucoma. and after
Suppresses edema, brain tumor, CV: Hypertension, applying
fibrin deposition, craniotomy, or heart failure, solution, and
capillary dilation, head injury. necrotizing angiitis. warn him not to
leukocyte Ulcerative ENDOCRINE: touch tip of
migration, capillary colitis, acute Growth retardation, dropper to eye
proliferation, and exacerbations of decreased or surrounding
collagen MS, and carbohydrate tissue.
deposition. palliation in tolerance, diabetes Tell patient to
some leukemias mellitus apply light finger
and lymphomas. GI: Peptic or pressure on
esophageal ulcer, lacrimal sac for
pancreatitis, 1 minute after
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIE
S
CONTRAINDICATIO HEMATOLOGIC: Warn patient not
NS: Fluid and to use leftover
Contraindicated in electrolyte drug for new eye
patients disturbances, inflammation;
hypersensitivity to increase blood doing so may
drug or its sugar, glycosuria, cause serious
ingredients. Drug increase serum problems.
contain sulphite. cholesterol.
Contraindicated in HYPERSENSITIVI
those with ocular TY: Anaphylactoid
tuberculosis or or hypersensitivity
acute superficial reactions.
herpes simplex MUSCULOSKELET
(dendritic AL: Muscle
keratitis), varicella, weakness, loss of
or other fungal or muscle mass.
viral diseases of Osteoporosis,
cornea and spontaneous
conjunctiva; in fractures
patients with OTHER: Impaired
acute, purulent, wound healing,
untreated petechiae,
 Cues Nursing Objectives Intervention Rationale Evaluation
Diagnosis
Subjective: Impaired physical mobility related General :
Maul-ol tak bali ha tiil to loss of integrity of leg bone After 4 days of holistic nursing
Dong structures care, the patient will be able to
reach OLOF.
Objective: Scientific Basis:
-Limited Range of 1.Encouraged significant others to reposition 1. To promote optimal level of functioning GOAL UNMET.
Fractures occur when the bone Specific:
Motion noted patient every 2 hours Still patient requires help
is subjected to stress greater After 8 hours of student nurse- from another person and
-Guarding behavior 2. Supported affected body part with soft 2. To maintain position of function and reduce
noted upon moving leg
that it can absorb. When patient interaction, the patient will equipment device
linen risk of pressure ulcers
-Slowed movement the bone is broken, adjacent be able to demonstrate a decrease
3. Encouraged participation in self care 3. To enhance sense of independence
noted structures are also affected, rate of dependence from 3 to 2
4. Provided safety measures 4. To ensure safety
-Rate of dependence resulting in soft tissue edema,
5. Administered meds as prescribed 5. To relieve pain pharmacologically
(3) three
hemorrhage into the muscles (ketorolac)
-Requires help from
and joints, joints dislocations, 6. Scheduled activity with adequate rest 6. To reduce fatigue
another person and
equipment device
ruptured ten-dons, severed periods
Source : Nurses Pocket
nerves, and damaged blood 7. Encouraged adequate intake of fluids and 7. To prevent constipation
Guide12th edition Doenges,
vessels. Body organs may be foods high in fiber
Moorhouse, Murr
injured by the force that caused 8. Check for skin integrity for signs of 8. Routine inspection of the skin (especially over
FUNDAMENTALS OF
the fracture fragments. After a redness and tissue ischemia (especially over bony prominences) will allow for prevention or
NURSING POTTER
fracture, the extremities cannot ears, shoulders, elbows, sacrum, hips, heels, early recognition and treatment of pressure
AND PERRY 8TH Edition
because normal functions ankles, and toes) ulcers
MEDICAL AND SURGICAL
of muscle depend on the 9. Note elimination status (e.g., usual 9. Immobility promotes constipation, decreasing
NURSING BRUNNER AND
integrity of the bones which they pattern, present patterns, signs of the motility of the gastrointestinal tract
SUDDARTHS 10TH Edition constipation)
are attached.
 Cues
Subjective:
Maul-ol tak bali ha tiil Dong

Objective:
Limited Range of Motion noted
Guarding behavior noted upon moving leg
Slowed movement noted
Rate of dependence (3) three
Requires help from another person and
 Nursing
Diagnosis
Impaired physical
mobility related to
loss of integrity of leg
bone structures
 Scientific Basis
Fractures occurwhen the bone is
subjected to stress greater that it
can absorb. When thebone is
broken, adjacent structures are
also affected, resulting in soft
tissue edema, hemorrhage into
the muscles andjoints, joints
dislocations, ruptured ten-dons,
Body organs may be
injured by the force that
caused the fracture
fragments. After a fracture,
the extremities cannot
because normal functions
ofmuscle depend on the
integrity of thebones which
 Objectives
General :
After 4 days of holistic nursing
care, the patient will be able to
reach OLOF.
Specific
After 8 hours of student nurse-
patient interaction, the patient
will be able to demonstrate a
Intervention Rationale
1.Encouraged significant 1. To promote optimal level of
others to reposition patient functioning
every 2 hours 2. To maintain position of
2. Supported affected body function and reduce risk of
part with soft linen pressure ulcers
3. Encouraged participation in 3. To enhance sense of
self care independence
4. Raised side rails up 4. To ensure safety
Intervention Rationale
5. Administered meds as 5. To relieve pain
prescribed (ketorolac) pharmacologically
6. Scheduled activity with 6. To reduce fatigue
adequate rest periods
7. Encouraged adequate 7. To prevent constipation
intake of fluids and foods
high in fiber
Intervention Rationale
8. Check for skin 8. Routine inspection of
integrity for signs of the skin (especially over
redness and tissue bony prominences) will
ischemia (especially allow for prevention or
over ears, shoulders, early recognition and
elbows, sacrum, hips, treatment of pressure
heels, ankles, and toes) ulcers
Intervention Rationale
9. Note elimination 9. Immobility
status (e.g., usual promotes
pattern, present constipation,
patterns, signs of decreasing the motility
constipation) of the gastrointestinal
tract
 Evaluation
GOAL UNMET
Still patient requires help
from another person and
equipment device
 Cues Nursing Objectives Intervention Rationale Evaluation
Diagnosis
Subjective : Fatigue related to General :
Makapoy it ak lawas disturbed sleeping pattern After 4 days of holistic
nursing care, the patient will
be able to reach optimum
Objective: leaving of functioning
Scientific Basis:
-Lethargic noted
Sleep restores our bodys
-Lack of energy noted Specific:
energy needs. People
1. Provided adequate rest 1.To promote optimal level of GOAL MET.
-Slowed movement After 8 hours of student
with decreased sleep may nurse-patient interaction, the functioning Patient demonstrated
noted
-Limited mobility noted
or will manifest decreased patient will be able to 2. Supported affected body 2. To maintain position of and verbalizes
-Fatigue rate of 7 out of energy level as evidenced verbalize and demonstrate a part with soft linen function and reduce risk of decrease fatigue rate
10, as 10 as the by lethargy and increased fatigue rate of 4-5 pressure ulcers of 5.
highest need for sleep
Source : Nurses Pocket 3.Instructed to avoid caffeine 3. To promote adequate sleep
Guide12th edition containing foods and drinks
Doenges, Moorhouse, Murr
FUNDAMENTALS OF
4. Provided safety measures 4. To ensure safety
NURSING 5. Scheduled activity with 5. To reduce fatigue
POTTER AND PERRY 8TH
adequate rest periods
Edition MEDICAL AND
SURGICAL NURSING
BRUNNER AND
SUDDARTHS 10TH Edition
 Cues Nursing Diagnosis Objectives Intervention Rationale Evaluat
ion
Subjective : Acute pain related to Left Leg Fracture General :
Maol-ol tak bali ha tiil Dong After 4 days of holistic nursing
Scientific Basis: care, the patient will be able to
Objective: Unpleasant sensory and emotional reach OLOF.
-Guarding behavior noted experiencing from actual tissue damage;
Pain scale of 5/10 sudden or slow onset with pain intensity from Specific:
mild to severe with an anticipated or After 8 hours of student nurse- 1. Instructed in and encouraged 1. To distract attention and GOAL Partially
C- sharp stabbing pain predictable end and a duration of less than 6 patient interaction, the patient will use of Deep Breathing Exercise reduce tension MET.
O-upon exertion of force on months. be able to verbalize a decreased 2. Provided hot and warm 2. to reduce pain via non Patient
affected leg Fractures occur when the bone is subjected to pain intensity to 3-4 demonstrated a
compress at interval frequency pharmacologic use
L-fractured site at Left lower leg stress greater that it can absorb. When pain scale of
3.Encouraged verbalization of 3. To report pain immediately
D-2-3 min the bone is broken, adjacent structures are 5/10
feelings
E- more movement of leg also affected, resulting in soft tissue edema,
D-deep breathing 4. Administered pain relievers 4. To reduce pain via
hemorrhage into the muscles and joints, joints
R-not dislocations, ruptured ten-dons, severed as ordered pharmacologic use
A-none nerves, and damaged blood vessels. Body Source : Nurses Pocket 5. Positioned at comfort 5.To reduce tension
organs may be injured by the force that caused Guide12th edition Doenges, 6.Maintain immobilization of 6.Relieves pain and prevents
the fracture fragments. After a fracture, the Moorhouse, Murr affected part by means of bed bone displacement and
extremities cannot because normal functions FUNDAMENTALS OF rest and mold extension of tissue injury.
of muscle depend on the integrity of the bones NURSING POTTER
which they are attached. AND PERRY 8TH Edition
MEDICAL AND SURGICAL
REFERENCE: FUNDAMENTALS OF NURSING BRUNNER AND
NURSING, MEDICAL AND SURGICAL SUDDARTHS 10TH Edition
NURSING
 Cues
Subjective :
Maol-ol tak bali ha tiil Dong
Objective:
Guarding behavior noted
Pain scale of 5/10
 C- sharp stabbing pain
O-upon exertion of force on
affected leg
L-fractured site at Left lower leg
D- 2-3 min
E- more movement of leg
R-deep breathing
R-not
A-none
 Nursing Diagnosis
Acute pain related to Left Leg
Fracture
 Scientific Basis
Unpleasant sensory and emotional experiencing
from actual tissue damage; sudden or slow
onset with pain intensity from mild to severe
with an anticipated or predictable end and a
duration of less than 6 months.
 Fractures occur when the bone is subjected to
stress greater that it can absorb. When
the bone is broken, adjacent structures are
also affected, resulting in soft tissue edema,
hemorrhage into the muscles and joints, joints
dislocations, ruptured ten-dons, severed
nerves, and damaged blood vessels. Body
organs may be injured by the force that caused
the fracture fragments. After a fracture, the
extremities cannot because normal functions
of muscle depend on the integrity of the bones
 Objectives
General :
After 4 days of holistic nursing care, the patient will be able to
reach OLOF.

Specific:
After 8 hours of student nurse- patient interaction, the patient
will be able to verbalize a decreased pain intensity to 3-4
 Intervention Rationale
1.Provided adequate rest 1.To promote optimal level of
2. Supported affected functioning
body part with soft linen 2. To maintain position of
3.Instructed to avoid function and reduce risk of
caffeine containing foods pressure ulcers
and drinks 3. To promote adequate
sleep
 Intervention Rationale
4. Provided safety 4. To ensure safety
measures
5. Scheduled activity with 5. To reduce fatigue
adequate rest periods
6. Administered 6. To aid pharmacologically
prescribed meds
(ketorolac)
 Evaluation
GOAL Partially MET.
Patient demonstrated
a pain scale of 5/10
 Cues Nursing Objectives Intervention Rationale Evaluation
Diagnosis
Subjective: Disturbed sleep pattern General: After 4 days
Diri ako nahingaturog related to discomfort of holistic student nurse
hin tuhay as resulting from current patient interaction the
verbalized by the illness or injury patient will be able to
patient achieve optimum level
SCIENTIFIC BASIS: of functioning.
Objective: Sleep is required to
- Change in normal provide energy for
sleep pattern physical and mental Specific:
- Restlessness activities . The sleep -After 8 hrs. of student- 1. Observed or 1. To determine usual GOAL PARTIALLY MET.
- Irritability wake cycle is complex , nurse patient interaction obtained feedback from sleep pattern and The patient demonstrated an increased number
- Slowed reaction consisting of different the patient will be able client regarding visual provide a comparative of hours of sleep 5-6 hours
- Lethargy stages of to demonstrate an sleeping routines, baseline .
- Disoriented consciousness , rapid increased number of number of hours of
- Decreased number eye movement. As hours of sleep 6-7 sleep.
of hours of sleep 3- persons age, the hours 2 Provided calm and 2. helps to promote
4 amount of time spent in quiet environment. conducive atmosphere
REM diminishes. The for rest full sleep.
amount of sleep that 3. Instructed client or 3. May irritate the
individuals require SO to avoid caffeinated bladder which can
varies with age and drinks like cola and cause diuresis over
personal characteristics coffee. stimulation prevents
such disruption may client from falling
result in both subjective asleep, delays client
distress and apparent falling asleep and
impairment in function shortens the REM part
abilities. Discomfort of sleep.
also contributes in 4. Positioned client 4. To promote rest.
changes in environment comfortably.
health and routine. 5.Encouraged deep 5. For relaxation
breathing exercises. technique.
6.Refered to physician 6.For specific
REFERENCE: or sleep specialist as interventions and or
FUNDAMENTALS OF indicated therapies, including
NURSING medications,
biofeedback
 Focus Charting
Date and Time Focus Problem Data Action Response
February 20, 2017 Disturbed sleeping Received patient on -Vital Signs taken and Kept watched
12:00 pm pattern bed sleeping with recorded
- Change in normal Intravenous Fluid of -Intake and Output
sleep pattern Plain Non-Saline Monitored
- Restlessness Solution 1 liter 980 -Positioned patient
- Irritability mL level at 30drops/ comfortably
- Slowed reaction minute infusing well -supported affected
- Lethargy at right arm, with leg with soft linen
- Disoriented Long Leg Posterior -encouraged
Mold Left, with Foley adequate intake of
Bag Catheter fluids and nutritious
attached to Urobag foods
infusing well; Diri ako -encouraged to do
nahingaturog hin deep breathing
tuhay as verbalized exercises
by the patient; -adequate rest
lethargic noted; provided
disoriented to time -balanced activity
and lace noted; with rest periods
-bed side care done
-Instructed client or
SO to avoid
caffeinated drinks like
cola and coffee.
 Date Focus Data Action Respons
and Problem e
Time
Februar Impaire -Received patient -Vital Signs taken and Kept
y 22, d on bed sleeping recorded watched
2017 Physical with Intravenous -Intake and Output Monitored
1:00 Mobility Fluid of Plain Non- -Positioned patient
pm Saline Solution 1 comfortably
liter kept set -supported affected leg with
sterile, with Long soft linen
Leg Posterior Mold -encouraged adequate intake
Left, with Foley of fluids and nutritious foods
Bag Catheter -encouraged to do deep
attached to breathing exercises
Urobag infusing -adequate rest provided
well; masakit akun -balanced activity with rest
tiil kun gikikiwa periods
as verbalized by -bed side care done
the patient.
 Date Focus
and Problem Data Action Respon
Time se
Februa Self Care -Received patient -Vital Signs taken and -kept
ry 23, Deficit on bed sleeping recorded watche
2017 with Intravenous -Intake and Output monitored d
1:00 Fluid of Plain Non- -positioned patient
pm Saline Solution 1 comfortably
liter kept set -assisted on wound dressing
sterile, with Long -supported affected leg with
Leg Posterior Mold soft linen
Left, with Foley -encourage to do Deep
Bag Catheter Breathing Exercise
attached to -adequate rest provided
Urobag infusing -performed bed bath
well; -emphasized the importance
Inability to bath of bed bath
self noted; -safety provided
guarding
Health Teaching Pla
n
Pathophysiol
ogy