CASE 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 over a widespread area, as well as
the extent of the damage.
 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 injuries each account for 10% of TBIs,
with the rest mild.
 NURSING
ASSESMENT
 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 wife
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
experienced other than that.
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 have
not comply because of financial
constraints.
 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
restrictions and any allergy.
 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 claimed that he
almost sleeps 8-10 hours a day.
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 little bit English.
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 guidance
from God and counsels his wife.
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 Test Normal Results Patients Results Significant Findings

Feb. Hemoglobin 130180 g/L 120g/L Decreased in all anemias in

13, count leukemia,
2017 and after hemorrhage
Hematocrit 42%52% 35 % Decreased in severe anemias,
count anemia of
pregnancy, acute massive blood
loss

Red Blood Cell 4.66.2 4.23 1012/L Decreased in various anemias,

Count 1012/L pregnancy,
severe or prolonged hemorrhage,
and with excessive fluid intake

White blood Cell 4.511 109/L 18.55 Increased in presence of infections

Count
Date Diagnostic Test Significant Findings

Feb. 15, 2017 Computed -Contusions, Frontal

Tomography and Left Occipital
area
-Left Occipital Bone
Fracture
-Minor Hemosinus,
Left Maxillary
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
RISPERIDONE, 2mg, THERAPEUTIC CLASS: Schizophrenia, CNS: parkinsonism, BEFORE:
1tab Oral, Hours of Antipsychotic Irritability, suicide attempt, Obtained baseline
sleep including somnolence, BP and monitored
aggression, self agitation, anxiety,
PHARMACOLOGIC injury and temper dizziness, fever, DURING:
CLASS: tantrums impaired Advised to avoid
Benzisozole associated with concentration, alcohol while
dermative an autistic abnormal thinking, taking this drug
disorder. dreaming tremor, AFTER:
fatigue, depression
MECHANISM OF Advised patient to
CONTRAINDICATION: CV: tachycardia, avoid alcohol
ACTION:
Hypersensitive to orthostatic Provided O2 when
Blocks dopamine and hypotension,
drug and in necessary
5h2 receptors in the peripheral edema,
breastfeeding Warned patient to
brain. HPN, syncope
women avoid activities
Caution in patients EENT: rhinitis, that require
with increase QT sinusitis, pharyngitis, alertness
interval double vision
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
GI: constipation, Monitored for S/S of
nausea, vomiting, overdose
abdominal pain, (Drowsiness,
anorexia, dry mouth, sedation,
increased saliva, tachycardia, hpn,
diarrhea, EPS, seizures
GU: urinary Instructed to do DBE
incontinence, increased Encourage Oral
urination, abnormal hygiene
orgasm, vaginal dryness Advised patient high
Metabolic: weight gain, fiber diet
hyperglycemia , weight Instructed patient to
loss elevate feet if not
Musculoskeletal: contraindicated
arthralgia, back pain,
limb pain, myalgia
Respiratory: dyspnea,
coughing, upper
respiratory tract
infection
Skin: rash, dry skin,
photosynsetivity, acne
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
DIAZEPAM, 5mg, 1 THERAPEUTIC CLASS: -Anxiety CNS: drowsiness, BEFORE:
tablet/ day, oral, hours Anxiolytic -Muscle Spasm dysarthria, slurred -Monitored V/S and BP
of sleep -Tetanus speech, tremor, -Assessed for
PHARMACOLOGIC transient amnesia, hypersensitivity
CLASS: CONTAINDICATION: fatigue, ataxia, DURING:
Benzodiazepine -Hypersensitive to drug headache, insomnia, -Warned patient to
or soya protein paradoxical anxiety, avoid activities that
MECHANISM OF -Experiencing shock and hallucination, minor require alertness
ACTION: coma changes in EEG pattern -Instructed SO to assist
-Acute angle closure CV: CV collapse,
& provided safety to
Probably potential the glaucoma bradycardia,
patient
effects of GABA, -Caution in patient with hypotension
depress the CNS and liver or renal EENT: diplopia, blurred -Advised increased fiber
supress the spread of impairment, vision diet & avoid alcohol
seizure activity depression, history of GI: constipation, AFTER:
substance abuse diarrhea with rectal -Monitored for
pain dizziness, ataxia, mental
GU: urinary state changes
incontinence & -Instructed patient not
retention to abruptly withdraw
RESPI: depression, drug.
apnea
SKIN: rash
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
CEFTRIAXONE, 500mg , THERAPEUTIC CLASS: -Perioperative GI: pseudomembranous - Instructed patient to
IVTT every 24 hours Antibiotic prevention colitis, diarrhea report discomfort at IV
(8am-8pm) -UTI, septicaemia, skin HEMA: Eosinophilia, site
PHARMACOLOGIC structure infection thrombocytosis, - Tell patient to report
CLASS: leukopenia adverse reactions
Third Generation CONTRAINDICATION: SKIN: pain, induration, promptly
Cephalosporin, -Hypersensitive to dry rash - Educated and informed
Pregnancy risk category or other cephalosporin OTHER: hypersensitivity about the adverse
B -Cautiously in patient reactions, anaphylaxis reactions
hypersensitive to
- Tell patient to notify
MECHANISM OF penicillin
prescriber if having
ACTION: -Cautiously in breast
Inhibits cell wall feeding women loose stools
synthesis, promoting - Assessed for pain
osmotic instability, - Administered pain
usually baactericidal meds. As prescribed
by the physician
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
Mannitol 100ml IVTT THERAPEUTIC CLASS: -To reduce intraocular CNS: seizures, dizziness, BEFORE:
every 12 hours (8 am- Diuretic or intracranial pressure headache, fever
8pm) or cerebral edema CV: edema, DURING:
PHARMACOLOGIC -To prevent oliguria or thrombophlebitis, -To relieve thirst, give
CLASS: acute renal failure hypotension, frequent mouth care or
Osmotic diuretic -Oliguria hypertension, heart fluids
failure, tachycardia, -Emphasized
MECHANISM OF CONTRAINDICATION: vascular overload importance of drinking
ACTION: -Hypersensitive to drug EENT: blurred vision, only the amount of
Increases osmotic -Anuria, active rhinitis fluids ordered.
pressure glomerular intracranial bleeding, GI: thirst, dry mouth,
filtrate, thus inhibiting severe dehydration, nausea, vomiting, AFTER:
tubular reabsorption of metabolic edema diarrhea -Monitored vital sign
H2O and electrolytes. It GU: urine retention and intake and output
elevates plasma META: dehydration -Instructed patient to
osmolarity and SKIN: local pain, promptly report
increased H2O flow into urticaria adverse reactions and
extracellular fluid. OTHERS: thirst, chill discomfort at I.V. site.
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
Ketorolac THERAPEUTIC CLASS: Short term CNS: Headache, Renal impairment,
Tromethamine 10 ml NSAID management of ain (up dizziness, insomnia, Impaired hearing,
IVTT every 8 hours (8 to 5days) fatigue, tinnitus, allergies, hepatic,
am- 4pm- 12 am) PHARMACOLOGIC Ophthalmic: Relief of ophthalmologic effects. Skin color and
CLASS: ocular itching due to DERMATOLOGIC: Rash, lesions, orientation,
NSAID seasonal conjunctivitis pruritus, sweating, dry reflexes, peripheral
and relief of mucous membranes, sensation, clotting
THERAPEUTIC ACTIONS: postoperative GI: Nausea, dyspepsia, times, CBC,
Anti inflammatory inflammation and pain GI pain, diarrhea, adventitious sounds
and analgesics activity; after cataract surgery. vomiting, constipation, Be aware that
inhibits prostaglandins flatulence, hepatic patient may be at
and leukotriene CONTRAINDICATIONS: impairment. risk for CV events, GI
synthesis. Contraindicated with GU: Dysuria, renal bleeding, renal
significant renal impairment toxicity, monitor
impairment, during HEMATOLOGIC: accordingly.
labor and delivery , Bleeding, decreased Keep emergency
lactation; patients Hgb and Hct equipment readily
wearing soft contact RESPIRATORY: Dyspnea, available at time of
lenses (ophthalmic); bronchospasm, rhinitis. initial dose, in case
aspirin allergy; OTHER: Peripheral of severe
concurrent use of edema hypersensitivity
NSAIDs; reaction.
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
active peptic ulcer Protect drug vials
disease or GI, bleeding; from light.
hypersensitivity to Administer every 6
ketorolac; as hours to maintain
prophylactic analgesics serum levels and
before major surgery; control pain.
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
RESPONSIBILITIES
Ranitidine THERAPEUTIC CLASS: Short term CNS: Headcahe, Instruct patient not
Hydrochloride IVTT Antiulcer treatment of active malaise, dizziness, to take new
25mg every 8 hours duodenal ulcer. insomnia, vertigo. medication w/o
(8am- 4pm- 12am) PHARMACOLOGIC Maintenance CV: Tachycardia, consulting physician
CLASS: therapy for duodenal bradycardia Instruct patient to
Histamine 2 ulcer at reduced DERMATOLOGIC: Rash, take as directed and
anatagonist dosage. alopecia do not increase dose
Short term GI: Constipation, Allow 1 hour
THERAPEUTIC ACTIONS: treatment of GERD. diarrhea, nausea, between any other
Competitively inhibits Short term vomiting, abdominal antacid and
the action of histamine treatment and pain,hepatitis. ranitidine
at the H2 receptors of maintenance GU: Impotence or Avoid excessive
the parietal cells of the therapy of active, decreased libido alcohol
stomach, inhibiting benign gastric ulcer. HEMATOLOGIC: Assess patient for
basal gastric acid Treatment and Leukopenis, epigastric or
secretion and gastric maintenance of granulocytopenia, abdominal pain and
acid secretion that is healing of erosive thrombocytopenia frank or occult blood
stimulated by food, esophagitis. LOCAL: Pain at IM site in the stool, emesis,
insulin, histamine, Treatment of local burning or itching or gastric aspirate
cholinergic agonists, heartburn, acid at IV site
gastrin, and indigestion, sour OTHER: Arthralgias
pentagastrin. stomach.
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
CONTRAINDICATION: Inform patient that it
Contraindicated with may cause
allergy to ranitidine, drowsiness or
lactation. dizziness
Inform patient that
increased fluid and
fiber intake 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
promptly
Inform patient that
medication may
temporarily cause
 DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
Dexamethasone THERAPEUTIC CLASS: Hypercalcemia CNS: Seizures, vertigo, Tell patient to shake
Sodium Sulphate IVTT Anti inflammatory associated with headaches, insomnia, suspension well
10mg every 8 hours cancer mood swings, before use.
(8am- 4pm- 12am) PHARMACOLOGIC Cancer depression, psychosis, Teach patient how to
CLASS: chemotheraphy intracerebral instill drops. Advise
Corticosteroid induced nausea and haemorrhage, him to wash hands
vomiting. cataracts, glaucoma. before and after
MECHANISM OF Cerebral edema CV: Hypertension, heart applying solution,
ACTION: associated with failure, necrotizing and warn him not to
Suppresses edema, brain tumor, angiitis. touch tip of dropper
fibrin deposition, craniotomy, or head ENDOCRINE: Growth to eye or
capillary dilation, injury. retardation, decreased surrounding tissue.
leukocyte migration, Ulcerative colitis, carbohydrate tolerance, Tell patient to apply
capillary proliferation, acute exacerbations diabetes mellitus light finger pressure
and collagen of MS, and palliation GI: Peptic or on lacrimal sac for 1
deposition. in some leukemias esophageal ulcer, minute after
and lymphomas. pancreatitis, abdominal instillation.
distention Advise patient that
GU: Amenorrhea. he/she may use eye
Irregular menses pad with ointment.
DRUG CLASSIFICATION INDICATION SIDE EFFECTS NURSING
RESPONSIBILITIES
CONTRAINDICATIONS: HEMATOLOGIC: Fluid Warn patient not to
Contraindicated in and electrolyte use leftover drug for
patients disturbances, increase new eye
hypersensitivity to drug blood sugar, glycosuria, inflammation; doing
or its ingredients. Drug increase serum so may cause serious
contain sulphite. cholesterol. problems.
Contraindicated in HYPERSENSITIVITY:
those with ocular Anaphylactoid or
tuberculosis or acute hypersensitivity
superficial herpes reactions.
simplex (dendritic MUSCULOSKELETAL:
keratitis), varicella, or Muscle weakness, loss
other fungal or viral of muscle mass.
diseases of cornea and Osteoporosis,
conjunctiva; in patients spontaneous fractures
with acute, purulent, OTHER: Impaired
untreated infections of wound healing,
eye; and in those who petechiae, ecchymosis,
have had increased sweating,
uncomplicated removal thin and fragile skin,
of superficial cornel acne
foreign body.
 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:
1.Encouraged significant others to reposition 1. To promote optimal level of functioning GOAL UNMET.
-Limited Range of
Fractures occur when the bone Specific:
patient every 2 hours Still patient requires help
Motion noted
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
that it can absorb. When patient interaction, the patient will equipment device
noted upon moving leg linen risk of pressure ulcers
-Slowed movement the bone is broken, adjacent be able to demonstrate a
3. Encouraged participation in self care 3. To enhance sense of independence
noted structures are also affected, decrease rate of dependence from
4. Provided safety measures 4. To ensure safety
-Rate of dependence (3) resulting in soft tissue edema,
3 to 2 5. Administered meds as prescribed 5. To relieve pain pharmacologically
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
ruptured ten-dons, severed periods
equipment device
nerves, and damaged blood 7. Encouraged adequate intake of fluids and 7. To prevent constipation
Source : Nurses Pocket
vessels. Body organs may be foods high in fiber
Guide12th edition Doenges,
injured by the force that caused 8. Check for skin integrity for signs of 8. Routine inspection of the skin (especially over
Moorhouse, Murr
the fracture fragments. After a redness and tissue ischemia (especially over bony prominences) will allow for prevention or
FUNDAMENTALS OF
fracture, the extremities ears, shoulders, elbows, sacrum, hips, heels, early recognition and treatment of pressure
NURSING POTTER AND ankles, and toes) ulcers
cannot because normal
PERRY 8TH Edition 9. Note elimination status (e.g., usual 9. Immobility promotes constipation, decreasing
functions of muscle depend on
MEDICAL AND SURGICAL pattern, present patterns, signs of the motility of the gastrointestinal tract
the integrity of the bones which
NURSING BRUNNER AND constipation)
they are attached.
SUDDARTHS 10TH Edition
 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 equipment
device
 Nursing Diagnosis
Impaired physical mobility
related to loss of integrity
of leg bone structures
 Scientific Basis
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 which they are
attached.
 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 decrease rate of dependence
from 3 to 2
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 Diagnosis Objectives Intervention Rationale Evaluation
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:
1. Instructed in and encouraged 1. To distract attention and GOAL Partially
mild to severe with an anticipated or After 8 hours of student nurse-
C- sharp stabbing pain predictable end and a duration of less than 6 patient interaction, the patient use of Deep Breathing Exercise reduce tension MET.
O-upon exertion of force on months. 2. Provided hot and warm 2. to reduce pain via non Patient
will be able to verbalize a
affected leg Fractures occur when the bone is subjected to decreased pain intensity to 3-4 compress at interval frequency pharmacologic use demonstrated a
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,
4. Administered pain relievers 4. To reduce pain via
D-deep breathing hemorrhage into the muscles and joints, joints
R-not as ordered pharmacologic use
dislocations, ruptured ten-dons, severed
A-none nerves, and damaged blood vessels. Body 5. Positioned at comfort 5.To reduce tension
Source : Nurses Pocket
organs may be injured by the force that Guide12th edition Doenges, 6.Maintain immobilization of 6.Relieves pain and prevents
caused the fracture fragments. After a fracture, Moorhouse, Murr affected part by means of bed bone displacement and
the extremities cannot because normal FUNDAMENTALS OF rest and mold extension of tissue injury.
functions of muscle depend on the integrity of NURSING POTTER AND
the bones which they are attached. 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
which they are attached.
 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 obtained feedback from sleep pattern and The patient demonstrated an increased number
- Slowed reaction consisting of different interaction the patient client regarding visual provide a comparative of hours of sleep 5-6 hours
- Lethargy stages of will be able to sleeping routines, baseline .
- Disoriented consciousness , rapid demonstrate an number of hours of
- Decreased number eye movement. As increased number of sleep.
of hours of sleep 3-4 persons age, the hours of sleep 6-7 2 Provided calm and 2. helps to promote
amount of time spent in hours 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
 Cues
maisog man hiya Dong kun diri
masunod it hiya gusto as verbalized
by her wife
-Irritable
-Verbal threats of violence
Diagnosis Scientific Basis Objectives Intervention Rationale Evaluation
Risk for self-directed violence related At risk for behaviours in which an General :
mental health problem individual demonstrates that he can After 4 days of holistic nursing care,
be physically, emotionally, and or the patient will be able to reach
sexually harmful to self and or others OLOF.
Specific:
After 8 hours of student nurse-
patient interaction, the patient will
be able to demonstrate self-control
as evidenced by nonviolent
behaviour
1.Observed and listened for early 1.May indicate possibility of loss of
cues of distress or increasing anxiety control, and intervention at this
point can prevent a blow up
2.Allows client to discuss feelings
2.Developed student nurse- client freely
trusting relationship Goal met; the patient doesnt
3.Discussed impact of behaviour on 3.To assist client to accept demonstrate violent behaviours.
others and consequences of actions. responsibility of impulsive behaviour
and potential for violence
4. Assisted client distinguish reality 4. To aid client validated to reality
from hallucinations by presenting
the reality
5. Administered prescribed
medications as prescribed (diazepam 5. To prevent and treat anxiety and
and respiredone)
psychosis
6. Identified support systems 6.Those who are around him need to
learn how to be a positive role
model and display a broader array of
skills of resolving problems
Doenges, 2013 Nurses Pocket Guide Diagnoses, Prioritized, Interventions, and Rationales
 Cues
maisog man hiya Dong kun diri
masunod it hiya gusto as
verbalized by her wife
-Irritable
-Verbal threats of violence
 Diagnosis
Risk for self-directed violence
related mental health problem
 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 self-control as evidenced by
nonviolent behaviour
 Intervention Rationale
4. Assisted client distinguish reality 4. To aid client validated to reality
from hallucinations by presenting the
reality 5. To prevent and treat anxiety and
5. Administered prescribed
medications as prescribed (diazepam psychosis
and respiredone)
6. Identified support systems
6.Those who are around him need to
learn how to be a positive role model
and display a broader array of skills of
 Intervention Rationale
4. Assisted client distinguish reality from hallucinations by 4. To aid client validated to reality
presenting the reality
5. Administered prescribed medications as prescribed
(diazepam and respiredone)
5. To prevent and treat anxiety and psychosis
6. Identified support systems
6.Those who are around him need to learn how to be a
positive role model and display a broader array of skills of
resolving problems
 Focus Charting
Date and Time Focus Problem Data Action Response
February 20, 2017 Disturbed sleeping pattern Received patient on bed -Vital Signs taken and Kept watched
12:00 pm sleeping with Intravenous recorded
- Change in normal sleep Fluid of Plain Non-Saline -Intake and Output
pattern Solution 1 liter 980 mL Monitored
- Restlessness level at 30drops/ minute -Positioned patient
- Irritability infusing well at right arm, comfortably
- Slowed reaction with Long Leg Posterior -supported affected leg
- Lethargy Mold Left, with Foley Bag with soft linen
- Disoriented Catheter attached to -encouraged adequate
Urobag infusing well; Diri intake of fluids and
ako nahingaturog hin nutritious foods
tuhay as verbalized by the -encouraged to do deep
patient; lethargic noted; breathing exercises
disoriented to time and -adequate rest provided
lace noted; -balanced activity with rest
periods
-bed side care done
-Instructed client or SO to
avoid caffeinated drinks
like cola and coffee.
Date and Focus Data Action Response
Time Problem
February Impaired -Received patient on -Vital Signs taken and recorded Kept
22, 2017 Physical bed sleeping with -Intake and Output Monitored watched
1:00 pm Mobility Intravenous Fluid of -Positioned patient comfortably
Plain Non-Saline -supported affected leg with soft
Solution 1 liter kept set linen
sterile, with Long Leg -encouraged adequate intake of
Posterior Mold Left, fluids and nutritious foods
with Foley Bag -encouraged to do deep breathing
Catheter attached to exercises
Urobag infusing well; -adequate rest provided
masakit akun tiil kun -balanced activity with rest periods
gikikiwa as verbalized -bed side care done
by the patient.
 Date Focus
and Problem Data Action Response
Time
Februar Self Care -Received patient on -Vital Signs taken and recorded -kept
y 23, Deficit bed sleeping with -Intake and Output monitored watched
2017 Intravenous Fluid of -positioned patient comfortably
1:00 pm Plain Non-Saline -assisted on wound dressing
Solution 1 liter kept -supported affected leg with soft linen
set sterile, with Long -encourage to do Deep Breathing
Leg Posterior Mold Exercise
Left, with Foley Bag -adequate rest provided
Catheter attached to -performed bed bath
Urobag infusing well; -emphasized the importance of bed
Inability to bath self bath
noted; -safety provided
guarding behaviour
noted upon moving
left leg.
Health Teaching Plan
Pathophysiology