Art Christian M.

Ramos BSN 4 - 3

Diagnosis: Close Complete Fracture @ R Leg September 3, 2013 Patient: Z

Diagnosis Anxiety (Mild) related to upcoming Surgical Procedur e Inference A vague uneasy feeling of discomfort or dread accompanied by an automatic response; the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat. Planning At the end 8hrs. of nursepatient interaction and intervention, the patient will: Lessen her anxiety Show increase comfort and manifest relaxation Have an understanding about the upcoming procedure

Assessment Subjective: Mejo kinakabahan ako sa operasyon ko bukas. as verbalized by the patient Objective:

Interventions

Rationale

Evaluatio n

Monitor Vital Signs

Serves as a Baseline Data

To increase patient understanding regarding surgical procedure and to gain a good coorperation from patient while doing nursing procedure.

Re-inforce doctor explanation using a simple language without medical jargon.

Received Awake, Conscious, and Coherent c Skin Traction to weights @ right leg + hematoma on Right upper cheeks and Right triceps brachii Initial Vital Signs taken and recorded as ff: T= 35.2C BP= 120/90mmH g RR= 22cpm PR=73bpm

Encourage patient to verbalized her feeling and ask question regarding surgical procedure.

To gain patient knowledge and patient cooperation also reduce the anxiety . To provide moral support to the patient.

Encourage family members give support and be with patient during doctor explanation and involve in nursing care.

Promotes well being and maximize

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Close Complete Fracture @ R Leg September 3, 2013 Patient: Z

Evidence of worrying

Encourage adequate intake of fluids and nutritious foods

energy production