Nursingcrib.com Nursing Care Plan Impaired Skin Integrity Traction)

Cues

Subjective ◊ “Nakuha nia ang sugat nya sa paa gawa nun nakabalot sa kanya sa traction,” as verbalized by the mother.

Objective ◊ c Buck’s traction @ L leg to 5 lbs weight

Nursing Diagnosis

Inference

◊ Impaired skin integrity r/t traction application

(vehicular accident))

Blunt Injury

Injury to femur/ Fracture

bleeding from damaged ends of bone & from surrounding tissue

breakage in skin ◊ c slightly dry bed sore & swelling @ L posterior foot application of Buck’s traction

bed sore

Objective

Nursing Intervention

Rationale

Short Term Goal

Independent

◊ After 4 days of nursing intervention, proper skin care will be demonstrated by the mother.

◊ Vital signs monitored and recorded.

◊ Changes in vitals signs may indicate infection.

◊ Demonstrated proper wound care.

◊ Cleaning the wound will minimize the risk for infection and further swelling.

◊ Advised the mother to elevate affected lower extremity from time to time.

◊ This controls swelling and pain. It also promotes venous return.

Evaluation

◊ After 4 days of nursing intervention, the goal is met through demonstration of proper skin hygiene and care.

Cues

Subjective ◊ “Medyo maputla sya simula nun pinasok sya dito,” as verbalized by the mother.

Objective ◊ c Buck’s traction @ L leg to 5 lbs weight ◊ c slightly dry bed sore & swelling @ L posterior foot ◊ c pale lips & conjuctiva ◊ Hgb level = 122g/L

Nursing Diagnosis

◊ Altered tissue perfusion r/t decreased Hgb concentration in blood, 122g/L

Inference

Circulatory impairment is one complication of the application of Buck’s traction. This is manifested by cold skin temperature, decreased peripheral pulses, slow capillary refill time and bluish skin.

Objective

Nursing Intervention

Rationale

Short Term Goal

Independent

◊ After 8 hours of nursing intervention, tissue perfusion will normalize & maintained.

◊ Vital signs monitored and recorded.

◊ Changes in vitals signs may indicate complication.

◊ Assessed circulation of the foot or hand. Checked for the peripheral pulses, color, capillary refill and temperature of fingers or toes.

◊ These characteristics of pulses, skin color, capillary refill time and temperature indicates impairment in blood circulation.

◊ Assessed for indicators of DVT, including calf tenderness, swelling and positive Homan’s sign.

◊ Deep Vein Thrombosis is another complication of circulatory impairment which also may be present on patients with Buck’s traction.

◊ Encouraged to perform foot exercises every hour when awake.

◊ This will promote venous return and better circulation.

◊ Advised to eat foods rich in iron such as organ meats, legumes & green leafy vegetables.

◊ Iron is a carrier of oxygen needed for cellular respiration.

Evaluation

◊ After 8 hours of nursing intervention, the goal is met through observation of pinkish lips & conjunctiva; and absence of other signs of circulatory impairment.