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(fracture) INFERENCE Trauma (Vehicular accident) PLANNING At the end 6hrs. of nurse-patient interaction and intervention, the patient will: INTERVENTION > Determine diagnosis that contributes to immobility. RATIONALE > To identify contributing factors EVALUATION After 6hrs. of nurse-patient interaction and intervention, the patient has: a) Verbalized understandin g of the situation and individual treatment regimen and safety measures. b) Participated in ADLs and desired activities c) Maintained position of function and skin integrity as evidenced by absence of decubitus ulcers d) Maintained and increased strength and function of affected part.
“Hindi ko maigalaw ung binti ko ”, as verbalized by the patient
>limited range of motion
>limited ability to perform gross and fine motor
> with cast on left leg
>Functional Level: 3
a) Verbalize understanding of the situation bleeding from and individual damaged ends of treatment bone and regimen and surrounding tissue safety measures. b) Participate in stimulates ADLs and inflammatory desired response activities c) Maintain position of function and increased capillary skin integrity permeability as evidenced by absence of decubitus fluid and cellular ulcers exudation d) Maintain and increase strength and pain function of affected part. impaired physical
Fracture of the left leg
> note situations such as fractures
> cause it may restrict movement
> determine the degree of immobility in relation to suggested scale
> to assess functional mobility
> determine presence of complications related to immobility (pneumonia, elimination problems,decubitus)
> to assess presence of complications
> Assist client reposition self on a regular schedule. > to promote optimum level of function and prevent
> Support affected body part using pillows.
> to maintain position and function and reduce risk of pressure ulcers. > Encourage adequate intake of fluids/nutritious foods
> It promote wellbeing and maximizes energy production
NURSING DIAGNOSIS Risk for infection related to wound secondary to fracture
INFERENCE Trauma (Vehicular accident)
PLANNING At the end of the 6hr nurse-patient interaction and intervention the patient will:
EVALUATION After 6hr nursepatient interaction and intervention the patient has :
>Note risk factor for >To assess occurrence of infection causative/ contributing factors
Fracture of the left leg
Objective: (+) presence of wound
bleeding from damaged ends of bone and surrounding tissue
a) Identify >Observe for localized interventions to signs of infection prevent/reduce risk of infection . b) Achieve timely wound healing; be free of purulent >Stress proper handhygiene by all caregivers bet. Therapies/clients.
>To assess for infected sites
a) identified interventions to prevent/reduce risk of infection b) Achieved timely wound healing; be free of purulent drainage or
>A first line defense against healthcareassociated infections
V/S taken as follows: Temp: RR: PR: BP:
broken skin (wound)
drainage or erythema; c) Be afebrile as evidenced by the normal V/S. >Recommend routine or body shower/scrub when indicated
>To reduce bacterial colonization
Risk for infection
>To prevent infection
c) Been afebrile as evidenced by the normal V/S.
>Change surgical or other wound dressings, as indicated, using proper technique for changing or disposing of contaminated materials
>Review individual nutritional needs,
>To promote wellness.