Ncp - Acute Pain -fracture

Nursing Diagnosis Acute pain related to surgery incision on left ankle

Scientific Analysis

Objective After 8 hours of nursing intervention, the patient:

Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or -verbalizes Subjective: injury as lasting from minimized or “Sakit ang ge- seconds to 6 months. In controlled operahan nga cases of fracture, pain is feeling of pain left ankle continuous and increasing nako”, as in severity until bone Verbalizes verbalized by fragments are immobilized. methods that the patient. In this type of fracture, the provide relief main medical management Objective: is open reduction with Demonstrate Incision on internal fixation (ORIF), use of the left ankle wherein the fracture relaxation (D/3 radius L fragments are reduced and skills and with bone internal fixation devices diversional grafting) are used to hold the bone activities fragment in position until Posterior solid bone healing occurs. casts and bandage on left ankle BP = 90 / 60 mmHg

Nursing Intervention Vital signs were monitored q 4 hours until stable and dressing was checked.

Rationale

Evaluation

Alterations from normal may be signs of infection. Moistened dressings are favorable site for microorganism to culture.

Pain is reduced / controlled to a tolerable extent as verbalized. Relieving methods and relaxation techniques are understood and demonstrated.

Adjusted constricting bandage and advised to elevate left leg

This is to prevent diminished circulatory and nerve function and control swelling of the site.

Instructed to do activities such as deep breathing exercise, coughing exercise and sitting exercises.

To reduce swelling and prevent stiffness the stated activities must be done. Decreased lung capacity and decreased cough efficiency are predisposing factors to respiratory infections.

Noted to avoid weight bearing until allowed.

To prevent from complications on the incision site, activities that may extend the cut must be avoided.

Encouraged to void freely.

This is advised in order to prevent constipation and fecal impaction.

Enough rest and sleep This promotes healing by was also advised. reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration. Intake of pain reliever and antibacterial

NSAID activity includes modulation of T-cell function, inhibition of