NURSING CARE PLAN 3 Cues

Date: 01 08 13 Time: 9:00 am S/O: T: 36.8 C P: 83 bpm R: 23 cpm BP: 90/70 mmhg (+) sutured wound left foot covered with elastic bandage Guarding behavior noted HEALTH

Need

Nursing Diagnosis

Objective

Nursing Interventions

Rationale
To have baseline data for future purposes. To assess patient condition. May indicate onset of local infection/tissue necrosis, which can lead to osteomyelitis

Evaluation
Date: 01 08 13 Time: 4:00 pm

PERCEPTION

HEALTH

MANAGEMEN

T PATTERN

Within 8 Monitor patient Risk for infection hours span vital signs. related to of care presence of patient will Encourage wound at left leg. be able to verbalization of Scientific Data: identify feelings. Fracture interventions Assess pin incomplete or to prevent or sites/skin areas, complete reduce risk noting reports of disruption in the of infection. increased continuity of pain/burning bone structure sensation or and caused by a presence of direct blow, edema, erythema, crushing force, foul odor, or sudden twisting drainage. motion. Provide sterile Resulting tissue pin/wound care edema, according to hemorrhage into protocol, and muscles or joints. exercise meticulous hand Clininal washing Manisfestation: Provide Acute Pain, opportunity of rest. deformity, loss of Document data on function, patients chart. shortening of the extremity, localized edema

Goal met, patient was free from infection.

May prevent crosscontamination and possibility of infection. To prevent fatigue. For legal purposes.