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Nursing

Cues Nursing Diagnosis Inference Objective Rationale Evaluation


Intervention

Subjective ◊ Impaired skin Blunt Injury Short Term Goal Independent ◊ After 4 days of
integrity r/t traction (vehicular accident)) nursing intervention,
◊ “Nakuha nia ang application ◊ After 4 days of ◊ Vital signs monitored ◊ Changes in vitals the goal is met
sugat nya sa paa nursing intervention, and recorded. signs may indicate through
gawa nun nakabalot Injury to femur/ proper skin care will be infection. demonstration of
sa kanya sa traction,” Fracture demonstrated by the proper skin hygiene
as verbalized by the mother. and care.
mother. ◊ Demonstrated ◊ Cleaning the wound
bleeding from proper wound care. will minimize the risk
Objective damaged ends of for infection and
bone & from further swelling.
◊ c Buck’s traction @ surrounding tissue
L leg to 5 lbs
weight ◊ Advised the mother ◊ This controls
breakage in skin to elevate affected swelling and pain. It
◊ c slightly dry bed lower extremity from also promotes venous
sore & swelling @ time to time. return.
L posterior foot
application of Buck’s
traction

bed sore
Nursing
Cues Nursing Diagnosis Inference Objective Rationale Evaluation
Intervention

Subjective ◊ Altered tissue Circulatory impairment Short Term Goal Independent ◊ After 8 hours of
perfusion r/t is one complication of nursing intervention,
◊ “Medyo maputla decreased Hgb the application of ◊ After 8 hours of ◊ Vital signs monitored ◊ Changes in vitals the goal is met
sya simula nun concentration in Buck’s traction. This is nursing intervention, and recorded. signs may indicate through observation of
pinasok sya dito,” as blood, 122g/L manifested by cold tissue perfusion will complication. pinkish lips &
verbalized by the skin temperature, normalize & conjunctiva; and
mother. decreased peripheral maintained. absence of other signs
pulses, slow capillary ◊ Assessed circulation ◊ These characteristics of circulatory
Objective refill time and bluish of the foot or hand. of pulses, skin color, impairment.
skin. Checked for the capillary refill time and
◊ c Buck’s traction @ peripheral pulses, temperature indicates
L leg to 5 lbs color, capillary refill impairment in blood
weight and temperature of circulation.
fingers or toes.
◊ c slightly dry bed
sore & swelling @
L posterior foot ◊ Assessed for ◊ Deep Vein
indicators of DVT, Thrombosis is another
◊ c pale lips & including calf complication of
conjuctiva tenderness, swelling circulatory impairment
and positive Homan’s which also may be
◊ Hgb level = 122g/L sign. present on patients
with Buck’s traction.

◊ Encouraged to ◊ This will promote


perform foot exercises venous return and
every hour when better circulation.
awake.

◊ Advised to eat foods ◊ Iron is a carrier of


rich in iron such as oxygen needed for
organ meats, legumes cellular respiration.
& green leafy
vegetables.

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