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Assessment

Background Knowledge Risk for The skin is the Impaired skin baseline defense of integrity related to the body against prolonged bed rest infection. Any and immobility break in the skin secondary to may harbor neuromuscular microorganisms impairment caused that may invade by the blood the normal insufficiency in processing of the the brains neurons body, which may due to transient inflict or aggravate Ischemic attack. the pts disease condition.

Diagnosis

Planning Goal: After 3 days of Nursing Intervention, the patient will be free of the from skin breakages. Objective: After 4 hr of nursing intervention the patientsrelatives will take actions regarding minimizing the risk through:

Intervention  Established therapeutic relationship  Monitored v/s  Assessed pts general condition

Rationale To gain pt and SOs trust and cooperation To obtain baseline data To note for the etiology or precipitating factors that can aggravate the risk.

Evaluation

a. Turning the patient from  Monitored I&O side to side b. Applying skin moisturizer c. Provides comfort  Encouraged d. Flattening all increase Oral the linens Fluid Intake to at least 2-3 liters per day  Arranged bed linens

To have a baseline data regarding input and output

To maintain hydration status

To prevent increase pressure and reduce risk for skin breakage

 Encouraged and assisted client to active and passive ROM exercises  Encouraged rest opportunities

To maintain good blood circulation

To promote optimum level of functioning

 Provided comfort measures and safety  Assisted client in changing positions every two hours  Provided Health information regarding the occurring problem  Provided conducive environment for resting  Encouraged client to have balanced diet

To let patient feel safe and comfortable

To prevent pressure ulcer

To lessen the pts feeling of anxiety

To promote rest and pts wellness

To promote adequate nourishment.

especially with increased intake of vitamin C and Protein.  Monitored and For proper Regulated IVF as replacement of fluid per doctors losses. order

Assessment

Diagnosis High risk for infection d/t inadequate primary defense as manifested by broken skin

Background Knowledge Complications of surgery include infection and poor wound healing are more likely to occur in the patient. Trauma on skin or an open wound can serve as an entry point for pathogens which increases the risk for infection

Planning Short-term Goal After 4 hours of nursing interventions, the patient will be:  Able to maintain temperature within normal range After 1 hour of nursing interventions, the patient will be:  Able to identify and verbalize interventions that will reduce the risk for infection

Intervention

Rationale

Evaluation

 Established rapport

To gain trust and cooperation of the patient An increase in the temperature may indicate signs of infection.

 Monitored v/s

 Assessed pts general condition

To note for the etiology or precipitating factors that can aggravate the risk Hand washing reduces the risks for infection

 Taught patient and its relatives to wash hands often, especially before toileting, before meals and before and after administering care  Discuss to patients the following signs

of infection redness, swelling, increased pain, or purulent drainage on the site and fever  Demonstrated and allowed return demonstration of wound care

To impart to the patient when the wound become infected and when to sought medical care

To know if the patient really understand the principle of proper wound care

Assessment

Diagnosis Risk for injury secondary to post anesthetic effects related to postoperative condition

Background Knowledge Post-operative patients may experiences drowsiness and muscle weakness as a post anesthetic effect. It's common to feel sleepy or disoriented for the first 15 minutes after awakening from anesthesia. Although these effects are usually temporary, sometime they can last as long as a few days or weeks. Being in a state of drowsiness and disorientation, a risk for injury occurs.

Planning Goals: Be free from injury

Intervention  monitored vital signs

Rationale for baseline data and record VS for documentation purposes to prevent injury in the post-op setting

Evaluation

Within the 8 hours of nursing care, the patient will be able  ascertained to: knowledge of safety needs or injury a.)modify prevention environment as motivation indicated to enhance safety  assessed clients muscle strength b.) demonstrate behaviours, lifestyle  provided healthcare changes to reduce within a culture of risk factors and safety protect self form injury  placed assistive devices  encouraged use of relaxation techniques  raised side rails  administered medication as prescribed by the doctor

to identify risk for falls to prevent errors resulting in client injury

to reduce risk of injury to reduce or manage stress

to prevent patient from fall to promote wellness