Nursing diagnosis Goal N.

Intervention Evaluation
Acute pain related to To minimize pain 1. Administer pain killer medication as Patient verbalized relief of
movement of bone fragment order. pain.
evidence by patient reported 2. Elevate and support injured
pain extremities.
3. Perform passive ROM.
4. Apply cold or warm compressor as
needed.

Impaired physical mobility To assist patient 1. Perform ROM regularly. Patient demonstrate increase of
related to ORIF surgery to restore activity 2. Evaluate need for assistance devices. mobility.
3. Assess safety of the environment.
4. Facilitate early ambulation.
5. Give medication as order.

Impaired skin integrity related To promote 1. Use strict aseptic technique when Wound healing achieved on
to mechanical interruption of wound healing changing dressing. time.
tissue and skin 2. Elevate operative area as order.
3. Inspect wound regularly.

Anxiety related to change in Patient will be 1. Provide pre and post operative Patient stated that he is relax.
health status able to rest education.
2. Identify fear level.
3. Control external stimuli such as
noise.
4. Administer anti-anxiety medication
or hypnotic as order.

Constipation related to Patient will 1. Measure abdominal distension Patient will be able to pass
immobility secondary to hip manage to pass regularly. stool every 1-2 days
fracture as evidence by stool 2. Start stool chart to record pattern of
difficulty to pass stool elimination.
3. Increase fluid intake.
 4. Encourage high fiber diet.
5. Administer laxative as order.
6. Encourage patient to walk.
Unstable blood glucose level To maintain 1. Monitor sign and symptoms for Blood glucose level
related to developmental level blood glucose hyperglycemia such as fatigue and maintained within normal
evidence by high reading in the level within dry mouth. range.
monitor normal range 2. Monitor blood glucose level
regularly.
3. Instruct patient to follow diabetic
diet.
4. Administer insulin on time as order.
5. Assess patient physical activity.

Decrease cardiac output related To maintain 1. Monitor blood pressure regularly. Blood pressure maintained
to vasoconstriction blood pressure 2. Observe skin color, dryness, and within normal range.
within normal capillary refill.
range 3. Administer medication as order.
4. Encourage patient to eat low salt
diet.
5. Encourage increase of physical
activity.

Knowledge deficit related to Patient will 1. Educate patient about his/her health Patient verbalized
unfamiliarity with information understand the condition. understanding of his/her
resources evidence by information 2. Answer all the questions honestly. condition.
misconception 3. Discuss importance of appointment
and follow health team instructions.

High risk for infection related To remain free of 1. Maintain hand washing. Patient remained free of
to tissue damaged (surgery) infection 2. Assess sign and symptom of infection.
infection.
3. Measure vital signs regularly.
4. Maintain strict sterile wound change
technique.