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Name: Romualde S.

Ison Diagnosis: History of injury, sustaining lacerated wound left leg r/o sepsis NURSING CARE PLAN ASSESSMENT Subjective: Mainit ang pakiramdam ko, tatlong araw na akong nilalagnat, as verbalized by the patient. NURSING DIAGNOSIS Increased body temperature (Hyperthermia) related to effects of toxins (bacteremia). INFERENCE NURSING INTERVENTION Tetanus is After 4 hours of Set the a disease nursing temperature a caused by a toxin interventions, the comfortable produced by the patients body environment bacteria temperature will called Clostridium subside within tetani. This toxin the normal can be found in range. soils heavy in manure or other organic material, particularly in Monitor body tropical or humid temperature regions of the every 2 hours hemisphere. Once the bacteria enters open wounds or Provide cuts it generates adequate spores, which in hydration or turn creates adequate neurotoxins. drinking Take action aseptic and antiseptic techniques in wound care. Give cold compress if no seizures PLANNING RATIONALE

Gender: Male Age: 48 years old

The environment can affect the condition and temperature of individual body as a process of adaptation through the process of evaporation and convection. Identify the symptoms progress toward exhaustion shock. Fluids help refresh the body and are a compression body from within. Nursing wounds eliminate the possibility of toxins that are still located around the wound. Cold compress is one way to lower body temperature

EVALUATIO N After 4 hours of nursing interventions, the patients body temperature subsided within the normal range.

Objective: Increase in body temperature above the normal range (38.10 degree Celsius) Body is warm to touch Skin redness especially on the infected area

occur external stimuli. Implement programs and antipyretic antibiotic treatment as ordered.

by means of conduction process. These drugs can have broad spectrum antibacterial to treat gram-positive or gram negative bacteria. Antipyretic worked as a process of thermoregulation to anticipate an increase in body temperature.

Collaborative Test results laboratory exam leukocyte increased ination of by more than leukocytes. 10,000 / mm 3 indicates infection and treatment or to follow the development of the programmed.

Name: Romualde S. Ison Diagnosis: History of injury, sustaining lacerated wound left leg r/o sepsis NURSING CARE PLAN ASSESSMENT Subjective: Hindi pa rin gumagaling yung sugat ko na nahiwa ng yero, as verbalized by the patient. NURSING DIAGNOSIS Impaired skin integrity related to mechanical factors. INFERENCE Tetanus is caused by the tetanus bacterium Clostridium tetani. Tetanus is often associated with rust, especially rusty nails, but this concept is somewhat misleading. Objects that accumulate rust are often found outdoors, or in places that harbour anaerobic bacteria, but the rust itself does not cause tetanus nor does it contain more C. tetani bacteria. The rough surface of rusty metal merely provides a prime habitat for C. tetani endospores to reside in, and the nail affords a means to puncture skin and deliver endospores deep within the body at the site of the wound. PLANNING

Gender: Male Age: 48 years old

Objective: Disruption of skin surface at left leg Localized erythema (+) Pain Swelling on the site of the wound

NURSING RATIONALE INTERVENTION Following a 3-day Assessed skin. Establishes nursing Noted color, comparative intervention, the turgor, and baseline client will be able sensation. providing to display Described and opportunity improvement in measured for timely wound healing as wounds and intervention. evidence by intact observed skin or minimize changes. presence of wound. Demonstrated Maintaining good skin clean, dry skin hygiene, e.g., provides a wash barrier to thoroughly and infection. pat dry Patting skin carefully. dry instead of rubbing reduces risk of dermal trauma to fragile skin. Instructed family to maintain clean, dry clothes, preferably cotton fabric (any T-shirt). Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection.

EVALUATION Following a 3-day nursing intervention, the client was able to display improvement in wound healing as evidenced by intact skin or minimize presence of wound.

An endospore is a nonmetabolizing survival structure that begins to metabolize and cause infection once in an adequate environment. Because C. tetani is an anaerobic bacterium, it and its endospores thrive in environments that lack oxygen. Hence, stepping on a nail (rusty or not) may result in a tetanus infection, as the lowoxygen (anaerobic) environment is caused by the oxidization of the same object that causes a puncture wound, delivering endospores to a suitable environment for growth.

Emphasized importance of adequate nutrition and fluid intake. Demonstrated to the family members on how to make a guava decoction to apply to the wound as alternative disinfectant. Instructed family to clip and file nails regularly. Provided and applied wound dressings carefully.

Improved nutrition and hydration will improve skin condition. Providing the family with alternative solution assists them in optimal healing with less expensive resources. Long and rough nails increase risk of skin damage. Wound dressings protect the wound and the surrounding tissues.