Fever Wound And Sprain Ncp
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ZAMORA, Maria Loreta B.
ASSESMENT S - “May natapakan akong laruan ng bata sa bahay, na-out of balance ako at tumumba. Doon ako nagkaroon ng sugat. Hindi naman ito malilim at hindi rin gaanong masakit. Kung I-rarate ko yung sakit. 5/10 lamang ito. Wala naman akong nararamdama ng kakaiba bukod ditto at matagal na din noong huli akong nagpainjection ng anti-tetano.” O - There are abrasions found on the client’s right knee. It is 4cm in diameter and has irregular borders. It is red in color due to a small presence of blood. The surrounding area shows sings of minimal swelling and is reddish in color. There are small
DIAGNOSIS
RATIONALE
Impaired skin integrity related to presence of wound
There is reported bleeding, pain and itchiness around the affected body part. Patient reports pain and itchiness around the affected area.
PLAN Goal:
INTERVENTION
•
After 30 minutes of nursing intervention:
The client’s wound will be free from injury.
The sensation felt by client will be lessened from 5/10 to at least 3/10.
•
Client’s sensation of itchiness will be• lessened or will be completely eradicated.
Objective:
Assess the client’s wound and record gathered data.
Perform proper • wound cleaning techniques
• Assessment is done in order to establish comparative baseline data of client’s present condition. Proper performance of wound cleansing will prevent further damage and infection. It also promotes wound healing.
Demonstrate to • the client and family members how to perform proper wound cleansing.
Provide the client and his family members with the knowledge of the benefits of proper wound cleansing will stress it’s importance to speedy wound healing.
Apply dressing to• the wounded area.
Wound dressing will protect the wound and the surrounding tissues from foreign substances and further injury.
Teach client how to do correct wound cleansing.
•
RATIONALE
EVALUATION After the 30 minutes of nursing intervention the client was able to demonstrate: • Absence of wound injury • A lessened sensation of pain felt • Absence of itching around the affected area.
N2-C NURSING CARE PLAN: WOUND ZAMORA, Maria Loreta B. N2-C NURSING CARE PLAN: FEVER ASSESMENT
DIAGNOSIS
RATIONALE
PLAN Goal:
S – “Kagabi suamasakit ng sobra yung sugat ko, parang tumitibok ung parte ng katawan ko na malapit sa sugat ko. Naramdaman ko na lang bigla mainit yung pakiramdam ko.” O - The client had warm to touch flushed skin, excessive sweating. Restlessness, body malaise
Upon assessment, the client’s vital signs were as follows: Temp: 39.0 °C PR: 80 beats/min RR: 18 breaths/min BP: 110/70 mmHG
Hyperthermia related to infection.
The body temperature is controlled by the hypothalamus, a section of the brain that acts just like your household thermostat. That is, if the body gets too cold, the thermostat sends out instructions to warm things up, and if it gets too hot, the thermostat tries to cool things down. When the body is faced with an infection, it responds in a number of ways.
After a 3 hour nursing intervention:
The client’s temperature will drop from 39.0°C to a normal range The client will show signs of comfort, reduced manifestations of restlessness
Objective:
The patient will be able to demonstrate normal thermoregulation behavior
INTERVENTION
•
Monitor patient’s vital signs
RATIONALE
•
EVALUATION
Assessment is done in order to establish comparative baseline data of client’s present condition.
After a 3 hour nursing intervention:
•
Provide a tepid sponge bath
•
Sponge baths increase heat loss through conduction
•
Reduce physical activity
•
Reduction of physical activity will limit heat production
•
Apply ice bag covered with a towel to the groin
•
To provide them with adequate knowledge on how to clean and dress wound to prevent further infection of the wound.
•
Weigh the client regularly
•
It is an indicator of overall fluid and nutritional status.
The client’s temperature was reduced to normal range The client, as verbalized, is comfortable and is no longer restless The client manifested signs of normal thermoregulator y behaviors.
ZAMORA, Maria Loreta B. N2-C NURSING CARE PLAN: SPRAIN ASSESMENT
DIAGNOSIS
S – “Nagmamadali akong bumaba ng hagdan kanina. Sa sobrang pagmamadali ko, nagka-mali ako ng tapak at nalaglag ako ng mga pitong baitang. Nakaramdam ako ng matinding sakit sa may paa ko pagkatapos. Hindi na nawala ang sakit na iyon hanggang ngayon. Noong sinubukang kong tumayo ay hindi na ako nakatayo. Kung Irarate ako ang sakit, 8/10 ito.”
Impaired Physical Mobility related to inflammation of the ankle joint
RATIONALE
PLAN Goal:
Behavior such as limitation in independent, purposeful physical movement of the body or of one or more extremities indicating loss of bone integrity was manifested
After a 2 hour intervention:
O - There is swelling and tenderness on the client’s left ankle There is un equal strength on both sides of the body Joint movement is not possible
Perform proper comfort measures the will ensure the client’s relief from pain. Pain sensation felt by the client will be reduced from 8/10 to 3/10 or less. Perform proper procedures that will promote faster sprain healing. The client will be able to demonstrate proper care of the injured joint.
INTERVENTION •
•
•
•
Objective: After 3 days of nursing intervention:
The client will be able to perform
•
Assess the client’s condition and the PQRST of pain felt. Apply cold compress for 15 minutes or less only within the first 24 hours of the occurrence of injury only. Apply splint to the sprained area and advice the client to rest.
Apply hot and cold compress alternately with 15-minute intervals. Advise to elevate affected extremity
RATIONALE •
•
•
•
•
To obtain baseline data for comparison of the development of the injury. This will aid in the vasoconstrictio n thus reducing blood flow and reducing inflammation Immobilization of the injured area will decrease the risk for further injury and will also prevent fatigue To aid in the healing of ligaments.
This will control
EVALUATION After a 2 hour intervention:
The pain sensation felt by the client was reduced
Proper procedures were performed that will ushered the client into a speedy recovery
The client was able to demonstrate proper care of the injured joint.
After 3 days of nursing intervention:
The client was able to perform activities of daily living with minimal assistance and was able to
activities of daily living with minimal assistance The client will show manifestations of return of normal musculoskeletal activity.
•
Educate the client and family members on how to reduce pain
swelling and pain •
This will reduce pain and promote independence on the client’s part
show manifestations of return of normal musculoskeleta l activity.
ASSESMENT S - “May natapakan akong laruan ng bata sa bahay, na-out of balance ako at tumumba. Doon ako nagkaroon ng sugat. Hindi naman ito malilim at hindi rin gaanong masakit. Kung I-rarate ko yung sakit. 5/10 lamang ito. Wala naman akong nararamdama ng kakaiba bukod ditto at matagal na din noong huli akong nagpainjection ng anti-tetano.” O - There are abrasions found on the client’s right knee. It is 4cm in diameter and has irregular borders. It is red in color due to a small presence of blood. The surrounding area shows sings of minimal swelling and is reddish in color. There are small
DIAGNOSIS
RATIONALE
Impaired skin integrity related to presence of wound
There is reported bleeding, pain and itchiness around the affected body part. Patient reports pain and itchiness around the affected area.
PLAN Goal:
INTERVENTION
•
After 30 minutes of nursing intervention:
The client’s wound will be free from injury.
The sensation felt by client will be lessened from 5/10 to at least 3/10.
•
Client’s sensation of itchiness will be• lessened or will be completely eradicated.
Objective:
Assess the client’s wound and record gathered data.
Perform proper • wound cleaning techniques
• Assessment is done in order to establish comparative baseline data of client’s present condition. Proper performance of wound cleansing will prevent further damage and infection. It also promotes wound healing.
Demonstrate to • the client and family members how to perform proper wound cleansing.
Provide the client and his family members with the knowledge of the benefits of proper wound cleansing will stress it’s importance to speedy wound healing.
Apply dressing to• the wounded area.
Wound dressing will protect the wound and the surrounding tissues from foreign substances and further injury.
Teach client how to do correct wound cleansing.
•
RATIONALE
EVALUATION After the 30 minutes of nursing intervention the client was able to demonstrate: • Absence of wound injury • A lessened sensation of pain felt • Absence of itching around the affected area.
N2-C NURSING CARE PLAN: WOUND ZAMORA, Maria Loreta B. N2-C NURSING CARE PLAN: FEVER ASSESMENT
DIAGNOSIS
RATIONALE
PLAN Goal:
S – “Kagabi suamasakit ng sobra yung sugat ko, parang tumitibok ung parte ng katawan ko na malapit sa sugat ko. Naramdaman ko na lang bigla mainit yung pakiramdam ko.” O - The client had warm to touch flushed skin, excessive sweating. Restlessness, body malaise
Upon assessment, the client’s vital signs were as follows: Temp: 39.0 °C PR: 80 beats/min RR: 18 breaths/min BP: 110/70 mmHG
Hyperthermia related to infection.
The body temperature is controlled by the hypothalamus, a section of the brain that acts just like your household thermostat. That is, if the body gets too cold, the thermostat sends out instructions to warm things up, and if it gets too hot, the thermostat tries to cool things down. When the body is faced with an infection, it responds in a number of ways.
After a 3 hour nursing intervention:
The client’s temperature will drop from 39.0°C to a normal range The client will show signs of comfort, reduced manifestations of restlessness
Objective:
The patient will be able to demonstrate normal thermoregulation behavior
INTERVENTION
•
Monitor patient’s vital signs
RATIONALE
•
EVALUATION
Assessment is done in order to establish comparative baseline data of client’s present condition.
After a 3 hour nursing intervention:
•
Provide a tepid sponge bath
•
Sponge baths increase heat loss through conduction
•
Reduce physical activity
•
Reduction of physical activity will limit heat production
•
Apply ice bag covered with a towel to the groin
•
To provide them with adequate knowledge on how to clean and dress wound to prevent further infection of the wound.
•
Weigh the client regularly
•
It is an indicator of overall fluid and nutritional status.
The client’s temperature was reduced to normal range The client, as verbalized, is comfortable and is no longer restless The client manifested signs of normal thermoregulator y behaviors.
ZAMORA, Maria Loreta B. N2-C NURSING CARE PLAN: SPRAIN ASSESMENT
DIAGNOSIS
S – “Nagmamadali akong bumaba ng hagdan kanina. Sa sobrang pagmamadali ko, nagka-mali ako ng tapak at nalaglag ako ng mga pitong baitang. Nakaramdam ako ng matinding sakit sa may paa ko pagkatapos. Hindi na nawala ang sakit na iyon hanggang ngayon. Noong sinubukang kong tumayo ay hindi na ako nakatayo. Kung Irarate ako ang sakit, 8/10 ito.”
Impaired Physical Mobility related to inflammation of the ankle joint
RATIONALE
PLAN Goal:
Behavior such as limitation in independent, purposeful physical movement of the body or of one or more extremities indicating loss of bone integrity was manifested
After a 2 hour intervention:
O - There is swelling and tenderness on the client’s left ankle There is un equal strength on both sides of the body Joint movement is not possible
Perform proper comfort measures the will ensure the client’s relief from pain. Pain sensation felt by the client will be reduced from 8/10 to 3/10 or less. Perform proper procedures that will promote faster sprain healing. The client will be able to demonstrate proper care of the injured joint.
INTERVENTION •
•
•
•
Objective: After 3 days of nursing intervention:
The client will be able to perform
•
Assess the client’s condition and the PQRST of pain felt. Apply cold compress for 15 minutes or less only within the first 24 hours of the occurrence of injury only. Apply splint to the sprained area and advice the client to rest.
Apply hot and cold compress alternately with 15-minute intervals. Advise to elevate affected extremity
RATIONALE •
•
•
•
•
To obtain baseline data for comparison of the development of the injury. This will aid in the vasoconstrictio n thus reducing blood flow and reducing inflammation Immobilization of the injured area will decrease the risk for further injury and will also prevent fatigue To aid in the healing of ligaments.
This will control
EVALUATION After a 2 hour intervention:
The pain sensation felt by the client was reduced
Proper procedures were performed that will ushered the client into a speedy recovery
The client was able to demonstrate proper care of the injured joint.
After 3 days of nursing intervention:
The client was able to perform activities of daily living with minimal assistance and was able to
activities of daily living with minimal assistance The client will show manifestations of return of normal musculoskeletal activity.
•
Educate the client and family members on how to reduce pain
swelling and pain •
This will reduce pain and promote independence on the client’s part
show manifestations of return of normal musculoskeleta l activity.
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