Assesment Nursing Analysis Planning Nursing Rationale Evaluation

Diagnosis Intervention
Objective:  Acute Pain  Unpleasant  Short  Independent: After
 Facial r/t bone sensory and -Term • Perform a o Prevents bone giving/providing
Grimace fracture in emotional Goal: comprehensi displacement/exten all the nursing
 Irritability the femur. experience • After ve sion of tissue intervention
 Restlessness from actual giving 4 assessment injury and Relieves needed by the
 Bruises Cues: or potential hours of of pain pain. patient, the
 Redness  Facial tissue nursing including patient will
Grimace damage or interventio location, experience no
 Swelling
 Irritability described in n the characteristi pain at all.
 Pain Scale
 Restlessness terms of patient cs,
of 7/10
 Bruises such will relief onset/duratio
 Vital Signs damage;
 Redness from pain n, frequency,
of: sudden or
 Swelling due to quality,
• BP- 130/90 slow onset fractured severity
• Temp.-  Pain Scale of any o decreases edema,
of 7/10
bone. • Maintain
37.9C intensity immobilizati and may reduce
• RR- 22 cpm from mild  Long – on of pain.
• PR- 89 bpm to severe Term affected part
with an Goal: • Elevate and o maintains strength
anticipated • After a support and mobility of
or shift the injured unaffected
predictable patient extremity muscles.
end and a will be • Perform and o Prevents boredom,
duration of experienci supervise reduces muscle
less than 6 ng no passive or tension, and can
months. In pain. active ROM increase muscle
this, the exercises. strength; may also
patient enhance coping
experience
pain due to • Suggest abilities.
bone diversional o Reduce pain.
fracture or activities
bone appropriate
damage. for client’s
age, physical
abilities, and
personal
preferences

 Dependent:
• Administer
medications o Reduce pain.
for bone
fractures, as
indicated.