Cues

Nursing Diagnosis

Inference

Objective

Nursing Intervention

Rationale

Evaluation

Subjective
◊ “Nakuha nia ang sugat nya sa paa gawa nun nakabalot sa kanya sa traction,” as verbalized by the mother.

◊ Impaired skin integrity r/t traction application

Blunt Injury

Short Term Goal
◊ After 4 days of nursing intervention, proper skin care will be demonstrated by the mother.

Independent
◊ Vital signs monitored and recorded. ◊ Changes in vitals signs may indicate infection.

(vehicular accident))
Injury to femur/ Fracture

◊ After 4 days of nursing intervention, the goal is met through demonstration of proper skin hygiene and care.

Objective
◊ c Buck’s traction @ L leg to 5 lbs weight ◊ c slightly dry bed sore & swelling @ L posterior foot

bleeding from damaged ends of bone & from surrounding tissue

◊ Demonstrated proper wound care.

◊ Cleaning the wound will minimize the risk for infection and further swelling.

breakage in skin

◊ Advised the mother to elevate affected lower extremity from time to time.

◊ This controls swelling and pain. It also promotes venous return.

application of Buck’s traction

bed sore

Short Term Goal ◊ After 8 hours of nursing intervention. legumes & green leafy vegetables. slow capillary refill time and bluish skin. ◊ Iron is a carrier of oxygen needed for cellular respiration. 122g/L Objective ◊ c Buck’s traction @ L leg to 5 lbs weight ◊ c slightly dry bed sore & swelling @ L posterior foot ◊ c pale lips & conjuctiva ◊ Hgb level = 122g/L Circulatory impairment is one complication of the application of Buck’s traction.” as verbalized by the mother. ◊ Changes in vitals signs may indicate complication. tissue perfusion will normalize & maintained. ◊ Encouraged to perform foot exercises every hour when awake. Checked for the peripheral pulses. capillary refill and temperature of fingers or toes. the goal is met through observation of pinkish lips & conjunctiva. decreased peripheral pulses. swelling and positive Homan’s sign. ◊ These characteristics of pulses. ◊ Assessed circulation of the foot or hand. capillary refill time and temperature indicates impairment in blood circulation. ◊ After 8 hours of nursing intervention. skin color. color. ◊ This will promote venous return and better circulation. ◊ Altered tissue perfusion r/t decreased Hgb concentration in blood. Independent ◊ Vital signs monitored and recorded. ◊ Deep Vein Thrombosis is another complication of circulatory impairment which also may be present on patients with Buck’s traction.Cues Nursing Diagnosis Inference Objective Nursing Intervention Rationale Evaluation Subjective ◊ “Medyo maputla sya simula nun pinasok sya dito. ◊ Assessed for indicators of DVT. including calf tenderness. . and absence of other signs of circulatory impairment. This is manifested by cold skin temperature. ◊ Advised to eat foods rich in iron such as organ meats.

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