NURSING CARE PLAN

Name of Patient: Mr. Rex Jun

Sex: Male

Diagnosis: Fracture, open II; shaft of 3rd metatarsal and 4th metatarsal and

Age: 17 years old

ASSESSMENT

DIAGNOSIS

RATIONALE

Subjective

Impaired physical

Trauma

none

mobility

r/t

fracture, open II;

of

3rd

Objective

metatarsal

and

Data:

4th

shaft

Functional

metatarsal

and
2 6th and 4th dorsal

level
(Requires
help

phalanx

(vehicular
accident)

Fracture of right
shaft of 3rd and

Limited
ROM

of

right

lower

with elastic

and

hours

the

intervention the

Assist to a

cooperation

patient

was

patient

semi-fowlers

To provide

able

to

position

comfort to the

participate

in

Monitor VS q

patient

ADLs

For baseline

desired

data and to

activities,

note the

change

changes of

position,

condition

was

To improve

sleep.

nursing

participate

will
in
and

4hrs

activities.

Bleeding from

Encourage
active ROM

lower

within level of

muscle

tolerance

strength and

Change

joint mobility

position q 2hrs

response

To promote
optimum level
of function and

Increase capillary
permeability

bandage in
place

rapport

desired

Stimulates

prevent

Encourage to
use crutches

Fluid and cellular

exudation

EVALUATION
At the end of 6

inflammatory

extremities

hours

RATIONALE
To gain trust

and 6th and 4th

as damaged ends of
bone and
person for manifested
by
surrounding
assistance, limited ROM of
tissue

or teaching) extremities

To establish

ADLs

accident

supervision, right

At the end of 6

4th metatarsal
dorsal phalanx

INTERVENTION

from vehicular

another

PLANNING

complication

To promote

when walking

independence

or wheelchair

and enhances
safety

and

able

and
to