Ncp For Post Op Wound And Fracture

Cues •

With post operativ e wound

Nursing Diagnosis Risk for infection related to inadequate primary defenses.

Background Knowledge Since skin is considered as the first line of defense from pathogens, when it is broken the chances of acquiring an infection increases. The manifestation of postoperative wound infection has a tri-factorial basis: the overall systemic trauma and the additional effects of premorbidity (age, diabetes, etc.), the local host damage resulting from both the

Objective At the end of the shift the patient shall be free from infection and all risks are minimized.

Intervention •

Assesse d wound area noting if clean, dry, intact, if incision s exhibit redness, edema, ecchym osis, drainag e, and approxi mation.

Rationale •

Assess ment provides informat ion about developi ng infectio n: Local inflamm atory effects cause redness and edema. This may be followed by purulent drainag e and would dehisce nce.

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Fever

Evaluation Patient exhibit no signs and symptoms of infection.

accident and surgery, and the bacterial contamination of the wound. The first factor is only moderately open to intervention, however, the amount of local host damage caused during the operation can be influenced directly by the surgeon who must ensure that his operating techniques are nonaggressive and in line with current knowledge.

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Assesse d tempera ture.

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Wound cleaning done aseptica lly.

may be the first sign of infectio n in the obstetri cs patient, and tempera ture values can have importa nt consequ ences for treatme nt decision s. •

Proper cleaning of wound using aseptic techniq

ue decreas es the risk for acquirin g infectio n.

Name: Magsuci, Giovani Address: Pandan, Ligao City Age: 32 Diagnosis: Exploratory Laparotomy secondary to rectal injury and impediment

Cues Subjective: • “I cannot

Nursing Diagnosis Impaired physical

Background Knowledge Trauma

Objective At the end of the shift the

Intervention •

determ ine the

Rationale •

to assess

Evaluation •

Verbaliz ed

move my left leg because it hurts.” Objective: • With limited range of motion • slowed movement • limited ability to perform gross and fine motor • with cast on left leg • Functional Level: 3

mobility related to loss of integrity of bone structures (fracture)

Fracture of the left leg

bleeding from damaged ends of bone and surrounding tissue

patient will verbalize understandin g of the situation and individual treatment regimen and safety measures.

degree of immobi lity in relation to sugges ted scale

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stimulates inflammatory response

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Assist client repositi on self on a regular schedu le.

increased capillary permeability

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fluid and cellular exudation

function al mobility

Encour age adequa te intake of fluids/

to promot e optimu m level of function and prevent complic ations

It promot e wellbeing and maximi zes energy product

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underst anding of the situatio n and individu al treatme nt regime n and safety measur es. Maintai ned and increas ed strengt h and function of affected part.

pain

nutritious foods

ion

impaired physical mobility •

Pain on left leg

Pain related to inflammatory response caused by tissue injury.

Cell and tissue injury

Vascular response

At the end of the shift the patient will verbalize a relief of pain.

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Provide comfor t measur es, quiet environ ment and calm activiti es.

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Encour age diversi onal activiti es and relaxati on techniq

Fluid exudation

pain

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To Patient promot verbalized e non relief of pain. -pharm acologi cal pain manage ment

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To distract attentio n and reduce tension

ues such as focuse d breathi ng and imagin g.

Name: Dollena, Keana Age: 8 y/o Diagnosis: Fracture, Closed, Complete, Displaced, Left leg