ASSESSME NT Subjective: Mainit ako, tatlong araw na akong nilalagnat, as verbalized by the patient. Objective: !

ncrease in body te"perature above the nor"al range #$%.& degree 'elsius( )ody is war" to touch Skin redness especially on the in*ected area

NURSING INFERENCE PLANNING DIAGNOSIS !ncreased body te"perature #+yperther"i a( related to e**ects o* to,ins #bactere"ia(. Tetanus is a disease caused by a to,in produced by the bacteria called 'lostrid iu" tetani. -his to,in can be *ound in soils heavy in "anure or other organic "aterial, particularly in tropical or hu"id regions o* the he"isphere. Once the bacteria enters open wounds or cuts it generates spores, which in turn creates neuroto,ins.

NURSING INTERVENTION

RATIONALE

EVALUATION

.*ter / hours 1Set the te"perature o* nursing a co"*ortable interventions, environ"ent the patient0s body te"perature will subside within the nor"al range. 1 Monitor body te"perature every 2 hours 1 3rovide ade4uate hydration or ade4uate drinking 1-ake action aseptic and antiseptic techni4ues in wound care. 15ive cold co"press i* no seizures occur e,ternal sti"uli.

-he environ"ent can a**ect the condition and te"perature o* individual body as a process o* adaptation through the process o* evaporation and convection. !denti*y the sy"pto"s progress toward e,haustion shock. 6luids help re*resh the body and are a co"pression body *ro" within. 7ursing wounds eli"inate the possibility o* to,ins that are still located around the wound. 'old co"press is one way to lower body te"perature by "eans o* conduction process.

8O75-9:M 5O.8: .*ter ; days o* nursing, interventions the patient able to "aintained and< i"proved sleep pattern as evidenced by / = hours o* sleep at night S+O:--9:M 5O.8: .*ter / hours o* nursing intervention the patient relatives was able to verbalized understanding o* necessary intervention to i"prove sleep pattern.

1!"ple"ent progra"s and antipyretic antibiotic treat"ent as ordered.

-hese drugs can have broad spectru" antibacterial to treat gra" positive or gra" negative bacteria. .ntipyretic worked as a process o* ther"oregulation to anticipate an increase in body te"perature.

1'ollaborative -est results leukocyte laboratory e,a"inatio increased by "ore n o* leukocytes. than >?,??? @ "" $ indicates in*ection and treat"ent or to *ollow the develop"ent o* the progra""ed.

CUES

S:di nga siya pwedeng tu"ayo sabi ni Aok verbalized by the husband o* the pt. O: #B( 8eg "uscle weakness 1!nability to per*or"ed .A8 1:eluctance to atte"pt "ove"ent 1 8i"ited range o* "otion 1Aoctors order o* '):. #B( -racheosto" y

NURSING DIAGNOSI S !"paired physical "obility r@t prescribed "ove"ent restriction. #6unctional level !C< Aependent, does not participate in activity.(

LONGTER M GOAL .*ter ; days o* nursing intervention the pt will be able to "aintain position o* *unction and skin integrity as evidence by absence o* contractures, *ootdrop, decubitus and etc..

SHORTTER M GOAL .*ter % hrs o* nursing intervention the patient relatives will be able to verbalize understanding o* situation and risk *actors and individual treat"ent and regi"en and sa*ety "easures.

NURSING INTERVENTION 1Monitored v@s

RATIONALE

EVALUATION

-o note changes and possible signs o* co"plication and serves as baseline data !t "ay result in activity intolerance

1.ssessed patient signs o* *atigue, pain and di**iculty o* breathing 1.ssisted client in repositioning every 2 hours or as needed 1 3rovided patient daily scheduled o* e,ercise 1 !nstruct patient@*a"ily regarding needs to "ake ho"e environ"ent sa*e

.*ter ; days o* nursing intervention the pt will be able to "aintain position o* *unction and skin integrity as evidence by absence o* contractures, *ootdrop, decubitus and etc.. S+O:--9:M 5O.8: .*ter % hrs o* nursing intervention the patient relatives will be able to verbalize understanding o* situation and risk *actors and individual treat"ent and regi"en and sa*ety "easures.

Opti"izes circulation and to all tissue and relieves pressure. -o enhance "ore his body "echanics . sa*e environ"ent is a prere4uisite to i"proved "obility.

1 3rovide sa*ety 6or sa*ety o* the pt. "easures as indicated in pt situation.

CUES S:Ai pa "agaling ung suagat niya gawa ng pag papaopera niya sa lala"unan as verbalized by the husband o* the pt. O: #B( 6loppy skin D= yrs old #B( -racheosto"y

NURSING LONGTERM SHORTTERM NURSING DIAGNOSIS GOAL GOAL INTERVENTION !"paired skin integrity r@t "echanical *actors secondary to surgery. .*ter ; days o* nursing intervention the pt relatives will be able to participate in prevention "easures and treat"ent progra". .*ter % hours o* nursing intervention the patient relatives will be able to verbalize understanding o* how to pro"ote early healing o* wound. 1Monitored vital signs

RATIONALE

EVALUATION

-o note changes and possible signs o* co"plication and serves as a baseline data

1Monitored *luid intake and output. 1.ssessed patient skin color, te,ture and turgor. 1!nstructed pt. relatives to keep area clean and dry 1!nstructed patient to apply lotion 1!nstructed patients 6a"ily to provide opti"u" nutrition including vita"ins and increase protein intake 19ncouraged patient to take "ultivita"ins

8O75-9:M 5O.8: .*ter ; days o* nursing intervention the pt relatives was able to participate in -o note *luid retention prevention "easures and treat"ent -o assess e,tent o* progra". involve"ent S+O:--9:M 5O.8: -o prevent *urther .*ter % hours o* co"plication nursing intervention the patient relatives -o "aintain was able to "oisturize skin verbalized understanding o* -o provide a positive how to pro"ote nitrogen balance to early healing o* aid in skin healing wound.

-o increase i""unity

CUES O: D= yrs old #B( -racheosto"y

NURSING DIAGNOSIS :isk *or in*ection related to inade4uate pri"ary de*ense

LONGTERM GOAL .*ter ; days o* nursing intervention the patient will be able to "aintain good hygiene

SHORTTERM GOAL .*ter / hours o* nursing intervention the patient relatives will be able to identi*y intervention that will prevent@reduce risk o* in*ection o* the patient

NURSING INTERVENTION 1Monitored vital signs

RATIONALE

EVALUATION

-o note changes and possible signs o* co"plication and serve as baseline data
3atients with poor nutritional status "ay be anergic, or unable to "uster a cellular i""une response to pathogens and are there*ore "ore susceptible to in*ection.

8O75-9:M 5O.8: .*ter ; days o* nursing intervention the patient was able to "aintained good hygiene S+O:--9:M 5O.8: .*ter / hours o* nursing intervention the patient relatives was able to identi*ied intervention that will prevent@reduce risk o* in*ection o* the pt.

1.ssessed patient nutritional status including history o* weight loss

1!nstructed patient o* daily bathing and hand washing 19ncourage intake o* protein and calorie rich *oods. 19ncouraged patient to take vita"ins such as vita"in '

-o reduce risk

-his "aintains opti"al nutritional status. -o increase and strengthen i""unity

CUES

NURSING DIAGNOSIS !ne**ective airway clearance r@t e,cessive "ucus secretions

LONGTERM GOAL !n ; days o* nursing intervention the patient will be able to e,pectorate@ clear secretions readily

SHORTTERM GOAL .*ter rendering i""ediate nursing intervention the pt will be able to "aintain airway patency

NURSING INTERVENTION 1Suction endotracheal

RATIONALE

EVALUATION

S< !nuubo pa rin siya. Cerbalized by the husband o* the pt.

-o clear airway when secretion are blocking airway. -o take advantage o* gravity decreasing pressure on the diaphrag" and enhancing drainage o* ventilation to di**erent lung seg"ent. -o note the any progress 8essen *atigue

8O75-9:M 5O.8: .*ter rendering i""ediate nursing intervention the pt was able to "aintain airway patency S+O:--9:M 5O.8: !n ; days o* nursing intervention the patient was able to e,pectorate but not cleared the secretions readily

O< #B( productive cough #B(Eide eyed #B(:estlessness

19levated head o* the bed, change position every 2 hours.

1Monitored vital sign 13rovided opportunities *or rest 1 .d"inistered O2 as needed

-o provide airway