DATE

CUES Objective cues: - Stitches noted on Right Upper Arm indicating a surgical wound

NEED H E A L T H P E R C E P T I O N H E A L T H M A N A A G E

DIAGNOSIS Risk for infection related to open wound as evidenced by dressing on the Right Upper Arm underwent an operation At increased risk for being invaded by pathogenic organisms. Source: Nurses Pocket Guide, Marilynn E. Doenges, Mary Frances, Moorhouse, Alice C. Murr

PLANNING

NURSING INTERVENTION

EVALUATION GOAL MET The patient was able to: - Be free of exposed wounds and sources of infections

A P R I L 2 7 , 2 0 1 2

- Dressing and bandages noted on Right Upper Arm indicating a surgical wound

Within 8 hours span Monitor vital signs especially of nursing care, the temperature patient will be able Reflective of inflammatory to: process/infection, requiring evaluation and treatment. - Maintain optimal amount of tissue Determine risk factors for revascularization occurrence of infection after rewarming understanding nature/properties of infectious agent and Have minimal determines choice of therapeutic damaging of tissues and tissue loss Observe for signs and symptoms of infective agent and sepsis. Initial symptoms of some agents presents with fever, fatigue, jointaches, and headache similar to influenza. Practice and demonstrate proper handwashing technique First-line defense to limit spread spread of infection Provide for infection precaution/ isolation as indicated To reduces risk of crosscontamination to staff, visitors, and other patient Group/cohort individual with same

M E N T

diagnosis/exposure as resources require limited resources may dictate open wardlike environment but need to control spread of infection still exists. Monitor visitors/caregivers for infectious disease Prevents exposure of patient to further infection and may reveal additional cases Promote nutritional needs, appropriate exercise program, and need for rest Essential for well-being and recovery. Instruct patient/SO in techniques to prevent spread of infection. self-care activities that may provide protection for patient/others Administer antibiotics as ordered Treats/prevents infections and sepsis

P A T T E R N

DATE

CUES Subjective Cues: Kapag may sugat yan siya medyo matagal gumaling as verbalized by the patients mother

NEED A C T I V I T Y E X E R C I S E P A T T E R N

DIAGNOSIS Risk for peripheral neurovascular dysfunction related to interruption of blood flow secondary to disease condition Trauma, edema or immobilization devices may interrupt tissue perfusion. Source: Brunner and Suddarths Textbook of MedicalSurgical Nursing

PLANNING

NURSING INTERVENTION

EVALUATION GOAL MET Within 8 hours span of nursing care, the patient was able to: - Maintain tissue perfusion as evidenced by palpable pulses, skin warm, normal sensation and stable vital signs

A P R I L 2 7 , 2 0 1 2

Objective cues: - Slow healing of lesion - Swelling of the wound at the Right Upper Arm - Abscess on the wound - Weak pulse on the Right Arm

At the end of the 8 Monitor vital signs hour span of care especially temperature the patient will be Reflective of inflammatory able to: process, requiring evaluation and treatment. -Maintain tissue perfusion as Practice and demonstrate evidenced by proper handwashing palpable pulses, technique skin warm, normal First-line defense to limit sensation and spread spread of stable vital signs microorganisms. Assess general condition of and contributing factors to patient. Provide basis for understanding geneal current situation of client. Evaluate presence/quality of peripheral pulse distal to injury via palpation. Decreased/absent pulse may reflect vascular injury and necessitates. Assess capillary return, skin color, and warmth distal to inflammation. Return of color should be rapid(3-5sec) White cold skin

indicates arterial impairement. Maintain elevation of inflamed extremity unless contraindicated by confirmed presence of compartmental syndrome. Promotes venous drainage/decreases edema. Investigate sudden signs of limb ischemia (e.g. decreased skin temperature, pallor, and increased pain). Osteomyelitis may cause damage to adjacent arteries, with resulting loss of distal blood flow. Encourage patient to routinely exercise digits/joints distal to inflammation Enhances circulation and reduces pooling of blood, especially in the lower extremities. Group/cohort individual with same diagnosis/exposure as resources require limited resources may dictate open wardlike environment but need to control spread of

infection still exists. Promote nutritional needs, appropriate exercise program, and need for rest Essential for well-being and recovery.