ASSESSMENT

BACKGROUND KNOWLEDGE

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: “Namamaga yung tahi ko sa kanang balakang ko, hindi kasi nalilinisan ng mabuti” as verbalized by the patient. Objective: (+)swelling (+)redness, warm to touch (+)pus on the site (+)drainage (+)inflammation (+)wound (4 inches of incision) Pain scale:6/10 -facial grimace VS: BP: 130/80 PR: 101 bpm RR: 24 cpm T: 38.5

Vehicular Accident femoral neck fractures total hip replacement open reduction with total hip prosthesis materials (acetabular component and femoral component) improper wound care infection ( swelling, inflammation, pain, redness, drainage, pus)

Infection secondary to open reduction with total hip prosthesis materials (acetabular component and femoral component) related to improper wound care as manifested by pain, inflammation, pus, redness, drainage and swellinkjkjkg

After 5 days of nursing intervention the patient will be free from infection and verbalize understanding of proper wound care.

INDEPENDENT INTERVENTION -Assess for wound >Redness, swollen, drainage is indicative of infection >Temperature, pulse and respiration increase in response to infection >pain may be due to wound, a possible locus of infection > relieve pain and reduce swelling avoid

-Monitor Vital signs

-Assess for pain

After 5 days of nursing intervention the patient was free from infection as evidenced by normal VS, absence of drainage from wound, inflammation, swelling and pus and was able to verbalize understanding of proper wound care. Goal was met.

-apply cold compress

-Maintain asepsis for >To dressing changes introducing and wound care infectious organisms.

-Teach the relative to >to reduces the wash hands before risk of transmitting contact with patient pathogens from one area of the body to another

-Restricts visitation > To reduce the by individuals with transmission of any type of infection pathogens to the patient. -Encourage intake of protein.Administer antibiotic >To reduce drugs as ordered. >Proper nutrition helps in efficient healing and faster recovery. thorough explanations and demonstrations about the proper wound care. iron. . >to know the proper caring for wound by himself or his relatives DEPENDENT INTERVENTION . and Vitamin A rich foods. calorie.Give clear. microorganism present in the body which causes infection . vitamin C.

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