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    NCP 2

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    JOPEARL MAE DELA TORRE
    1. The patient presented with a fractured tibia and fibula from a fall, which caused chronic pain, swelling, and inability to move the lower leg. 2. After 4 hours of interaction with the nurse, the patient was able to properly use assistive devices and show progress in mobility without pain. 3. The goals of treatment were to relieve pain, prevent complications, and restore mobility and independence through exercises and proper use of assistive devices.

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    NCP 2

    Uploaded by

    JOPEARL MAE DELA TORRE
    79 views2 pages
    1. The patient presented with a fractured tibia and fibula from a fall, which caused chronic pain, swelling, and inability to move the lower leg. 2. After 4 hours of interaction with the nurse, the patient was able to properly use assistive devices and show progress in mobility without pain. 3. The goals of treatment were to relieve pain, prevent complications, and restore mobility and independence through exercises and proper use of assistive devices.

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    36571311-NCP-2

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    1. The patient presented with a fractured tibia and fibula from a fall, which caused chronic pain, swelling, and inability to move the lower leg. 2. After 4 hours of interaction with the nurse, the patient was able to properly use assistive devices and show progress in mobility without pain. 3. The goals of treatment were to relieve pain, prevent complications, and restore mobility and independence through exercises and proper use of assistive devices.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    79 views2 pages

    NCP 2

    Uploaded by

    JOPEARL MAE DELA TORRE
    1. The patient presented with a fractured tibia and fibula from a fall, which caused chronic pain, swelling, and inability to move the lower leg. 2. After 4 hours of interaction with the nurse, the patient was able to properly use assistive devices and show progress in mobility without pain. 3. The goals of treatment were to relieve pain, prevent complications, and restore mobility and independence through exercises and proper use of assistive devices.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    Patient: Mr.

    R Diagnosis: Fractured Tibia, Fibula Open Type II Complete, Comminuted 25 M


    Assessment Diagnosis Scientific Basis Planning Intervention Rationale Evaluation
    Subjective Data: Chronic pain > A break in the Goal: Independent: > Identifying the After 4 hours of
    Patient verbalized,related to swelling bone is known as a After 4 hours of > Assess specific cause guides nurse- patient
    fracture. There are
    “Ngul-ngul akong and tenderness of nurse- patient symmetry, design of optimal interaction, the
    two main types of
    tiil”. the fractured fracture: the simple
    interaction, the strength, degree treatment plan. patient was able
    lower leg, and (close) and patient will be of mobility. >This optimizes to properly use
    Objective Data: inability to move compound (open). able to use > Position patient circulation to all assistive devices
    RR= 27 cpm purposefully in the The simple fracture assistive in proper body tissues and relieves as provided.
    T°= 36.6°C environment is a break in the equipment alignment. pressure. Patient was also
    bone that does not
    BP= 100/70 including mobility, properly, show > Encourage >Exercise promotes able to progress
    pierce the skin or
    mmHg transfers, and cause severe
    progress in isometric exercises increased venous in mobilization
    PR= 76 bpm ambulation damage to mobility on bed, when indicated. return, prevents through exercises
    > Patient is secondary to surrounding tissues. and be able to > Teach proper stiffness, and and was slowly
    unable to move fractured tibia, In the compound transfer without use of assistive maintains muscle able to move
    lower leg. fibula open type fracture, the skin feeling any pain. device such as strength and himself up in bed
    and tissues are
    > Skin is II complete, crutches. endurance. without pain.
    broken through. A
    discolored comminuted 25 fracture may also be
    Planned Actions: > Provide >Proper use of Patient was also
    > Swelling of M. complete, dividing the > Maintain or progressive wheelchairs, canes, able to properly
    skin noted bone into two or increase strength mobilization. transfer bars, and groom himself
    > Grimacing of more separate and endurance of other assistance can without help.
    patient’s face was pieces. It may be fractured lower Dependent: promote activity and Patient was able
    also incomplete or
    noted leg. >Passive/active reduce danger of to take the
    partial. In a
    > Patient is not comminuted fracture,
    > Make sure no ROM exercises as falls. prescribed
    properly groomed the bone is broken complications will ordered by >The longer the medication.
    into little pieces at develop during physician to the injured patient remains
    the point of fracture. body part.
    Medical Diagnosis: (Reader’s Digest immobilization. > Administer proper immobile the greater
    Fractured Tibia, Family Health Guide > Demonstrate medication as the risk of
    and Medical
    Fibula Open Type the proper use of prescribed by the complications.
    Encyclopedia)
    II Complete, > Lower leg
    assistive devices. physician. (www1.us.elsevierheal
    Comminuted 25 fractures include the th.com)
    M fractures of the tibia Expected Collaborative:
    and fibula. Of these Outcome: > Refer the
    two bones, the tibia > Patient would patient to a PT
    is the only weight
    be able to move or an OT.
    bearing bone.
    Fractures of the tibia
    lower leg with
    are generally less pain.
    associated with fibula > Patient will be
    fracture because the able to groom
    force is transmitted himself.
    along the
    > Patient will be
    interosseous
    membrane to the
    relieved from pain
    fibula. after administering
    (eMedicine.com) proper medication.
    > Causes include
    direct forces such as
    those caused by falls
    and motor vehicle
    accident.
    (eMedicine.com)
    Name of Student: Bongon, Claudine Y. BSN1-N1

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