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URDANETA CITY UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN


MONTH/YEAR OF EXPOSURE: JULY 08 - JULY 19, 2019
AFFILIATING AGENCY/AREA: MANILA AFFILIATION-PHILIPPINE ORTHOPEDIC CENTER
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: High risk for infection After 2 hrs of nursing Independent:
“inoperahan yung due to inadequate intervention the pt will  Establish rapport  To gain trust and After 2hrs of nursing
kanang paa nya dahil sa primary defense as gain knowledge in cooperation of intervention the pt. will
aksidente ” as verbalized manifested by broken infection control as the patient. be able to gain
by Grandmother skin evidenced by discussing  Teach pt to wash  Hand washing knowledge in infection
the wound care. hands often reduces the risk control as evidenced by
Objective : Scientific Explanation: especially before for infection. his discussion in wound
(+) swelling toileting ,before care. Therefore,the
(+) tenderness Trauma on skin @ right and after goal was met.
(+) wound discharge leg distal , fibula administering
(+) limitation of ROM self-care
In right leg
Broken skin  Discuss to pt the  To impart to the
following sighs of pt when the
V/S: infection wound become
Temp: 36.5 Open wound redness, swelling infected and
PR: 83 increased pain, when sought
RR: 21 or purulent medical care
BP: 110/70 mmhg Risk for infection drainage on the
site and fever
Medical Diagnosis:
URDANETA CITY UNIVERSITY
COLLEGE OF NURSING

Fracture open 3b  Provide  To lessen anxiety


complete displaced emotional
distal ,fibula (R) support

Dependent:
 Administer
proper
medication as
prescribed by
the physician.

Collaborative:
 Refer to the
physician or
physiotherapist.
URDANETA CITY UNIVERSITY
COLLEGE OF NURSING

Prepared by: Submitted to:

Espiritu Efrain S. Mr. Rodney E. Salagubang, PTRP., RN., MAN.


Name of Student Clinical Instructor
BSN III July 08, 2019- July 19 2019