Patient: Soledad, Juli Admitting Diagnosis: Post-Debridement with Jackson Pratt Drain Assessment Risk/Abnormal cues Mechanical head

d injury Postoperative surgery of the head Weakness and limitation in motion of body parts Strengths Strong family support Good compliance to treatment and medications Nursing Diagnosis Risk for peripheral neurovascular dysfunction related to mechanical trauma of the head Definition: At risk for disruption in circulation, sensation, or motion of an extremity. Source: Doenges, M.E, et. Al. Nurses Pocket Guide Edition 11. F.A. Davis Company. Philadelphia, Pennsylvania. 2008. Rationale Multiple hack wound at the temporoparietal and neck area due to mechanical trauma Neuromuscular involvement due to head injury and undergone surgical intervention of debridement with Jackson Pratt drain Trauma to underlying soft tissues and nerves of the brain Desired Outcomes After 4 days of nursing interventions, the patient will be able to: 1.)Maintain function as evidenced by sensation/ movement within normal range for the individual 1.1 assess for individual risk factors: 1.) trauma to extremity that cause internal tissue damage 2.) Immobility 3.) Smoking, obesity, and sedentary lifestyle. 1.2 Note position of casts in the head 1.3 Perform neurovascular assessment in person immobilized for any reason or individuals with suspected neurovascular problems. 2.1 ask client to localize pain/ discomfort and to report numbness and tingling or presence of pain with exercise o rest 1.1 that potentiate risk of circulation insufficiency and occlusion Nursing Interventions Justifications Evaluation

Risk for peripheral neurovascular dysfunction related to mechanical trauma of the head Source: Medical-Surgical
Book Edition 16 by Williams and Wilkins.

1.2 to ascertain potential for pressure on tissues 1.3 provides baseline for future comparison

2.)Demonstrate or participate in behaviors and activities to prevent

2.1 to detect any abnormalities and assess the part affected

complications.

2.2 encourage client to routinely exercise digits/ joints distal to injury. Provide passive Range of motion exercise of the extremities 3.1 assess presence, location, and degree of swelling/ edema formation. Measure affected extremity and compare with unaffected extremity.

2.2 to enhance circulation of the periphery and improve muscle strength

3.) Relate signs/symptoms that require medical reevaluation.

3.1 to immediately detect any complications and be intervened the affected part