Cues Nursing Background Objective Intervention Rationale Evaluation

Diagnosis Knowledge

• With Risk for Since skin is At the end of • Assesse • Assess Patient exhibit
post infection considered as the shift the d wound ment no signs and
operativ related to the first line of patient shall area provides symptoms of
e wound inadequate defense from be free from noting if informat infection.
primary pathogens, infection and clean, ion
defenses. when it is all risks are dry, about
broken the minimized. intact, if developi
chances of incision ng
acquiring an s exhibit infectio
infection redness, n: Local
increases. The edema, inflamm
manifestation ecchym atory
of osis, effects
postoperative drainag cause
wound e, and redness
infection has a approxi and
tri-factorial mation. edema.
basis: the This
overall may be
systemic followed
trauma and by
the additional purulent
effects of drainag
premorbidity e and
(age, diabetes, would
etc.), the local dehisce
host damage nce.
resulting from
both the • Fever
accident and may be
surgery, and the first
the bacterial • Assesse sign of
contamination d infectio
of the wound. tempera n in the
The first factor ture. obstetri
is only cs
moderately patient,
open to and
intervention, tempera
however, the ture
amount of values
local host can
damage have
caused during importa
the operation nt
can be • Wound consequ
influenced cleaning ences
directly by the done for
surgeon who aseptica treatme
must ensure lly. nt
that his decision
operating s.
techniques are
non- • Proper
aggressive cleaning
and in line of
with current wound
knowledge. 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 Nursing Background Objective Intervention Rationale Evaluation

Diagnosis Knowledge

Subjective: Impaired Trauma At the end of • determ • to • Verbaliz

• “I cannot physical the shift the ine the assess ed
 move my mobility patient will degree function underst
left leg related to verbalize of al anding
because it loss of Fracture of understandin immobi mobility of the
hurts.” integrity of the left leg g of the lity in situatio
bone situation and relation n and
structures individual to individu
Objective: (fracture) bleeding from treatment sugges al
• With limited damaged regimen and ted treatme
range of ends of bone safety scale nt
motion and measures. • to regime
• slowed surrounding promot n and
movement tissue e safety
• limited • Assist optimu
client measur
ability to m level es.
perform repositi of
on self • Maintai
gross and stimulates function
on a ned and
fine motor inflammatory and
regular increas
• with cast on response prevent
schedu ed
left leg complic strengt
• Functional le. ations h and
Level: 3 increased function
capillary of
permeability • It affected
promot part.
• Encour
age e well-
fluid and adequa being
cellular te and
exudation intake maximi
of zes
fluids/ energy
product
 pain nutritious ion
foods

impaired
physical

mobility

• Pain on left Pain related Cell and At the end of • Provide • To Patient
leg to tissue injury the shift the comfor promot verbalized
inflammatory patient will t e non relief of pain.
response verbalize a measur -pharm
caused by Vascular relief of pain. es, acologi
tissue injury. response quiet cal pain
environ manage
ment ment
and
calm
activiti
es.
Fluid
exudation
• To
• Encour distract
age attentio
diversi n and
onal reduce
pain activiti tension
es and
relaxati
on
techniq
 ues
such as
focuse
d
breathi
ng and
imagin
g.

Name: Dollena, Keana

Age: 8 y/o

Diagnosis: Fracture, Closed, Complete, Displaced, Left leg