1 1 acute pain After the nursing 1. Examine the 1.To determine
associated with care plan given for 3 location and the right pain joints shift x24 hours expected scale of the pain in the right marked by bone the result are : 2. Observation vital location and and tissue signs of the 2. To know the trauma 1 pain can be patient patient characterized by : reduced 3. Teach patient progress S : patient 2 patient look calm relaxation and 3. to divert the complaint the and more relaxed distraction patient pain techniques attention , so O : patients face 4. Collaborate with that patient are look grimace the doctor to not focus on his give the patient pain analgetic 4. to reduce the medicine patients pain Dx 2
no Nursing diagnosis Goals intervention Rationale
2. physical After the nursing care - Examine the -to
immobility related give in during 3x24 hour patients ability identification to the pain of expected that: and functionally the main friction joints - Patient can state on the problem characterized by returns to damage area disturbance of stiffness in the normal mobility - Monitoring the physical joints . characterized - Patien can motoric function mobilitation by : mantain his and sensory - identification S: patint complain joint movement function the disturbance that he can not do to the maximal everyday of physical the activity and hard - Muscle - Do the passive mobilitation to move strength ROM exercisess and the patient O:patient look weak become - Change the progress and his activity daily maximal patient potition -to determine living assisted by his - Skin integrity after two hours the patient family become intact - Observation the ability to do the skin condition mobilitation - Give the skin -prevent the tretment occurence of carefully like contractures massage and give oil -the continuing moisturizer and pressuress can change linen or causes patient clothing decubitus if the linen or -to preventing clothes are wet the decubitus - Collaborate earlier patient’s activity -to increase to the circulation and physiotherapist clasticity of patient’s skin and decrease the possibility of decubitus -to collaborate the patient’s activity to the therapist