Pathophysiologic/

Assessment Cues Nursing Diagnosis Desired Outcome Nursing Intervention Rationale Evaluation
Schematic Diagram

Subjective: Risk for impaired Predisposing Factors: After of 8 hours of Independent: After 8 hours of nursing
“ Gusto ko gid tani tissue Age nursing interventions the - Examine the skin for open - Provides information intervention patient was able
to verbalized relief of
mag giho-giho kaso integrity/pressure ulcer patient will be able to wounds, foreign bodies, rashes, regarding skin discomfort, demonstrated
tungod sa akon na as evidenced by Precipitating Factors: verbalize relief of bleeding, discoloration, duskiness, circulation and behaviors or techniques to
injury indi ko mayo decreased in mobility environment discomfort, demonstrate and/or blanching. problems that may be prevent skin breakdown and
ka giho” as Loss of sensory behaviors or techniques caused by application facilitate healing. Goal met.
verbalized by the Definition: aids/clues to prevent skin and/or restriction of
patient. At risk for skin being breakdown and facilitate cast, splint, or traction
adversely altered S/S healing, as indicated. apparatus, or edema
Difficulty using the formation that may
Objective: Source: limb require further medical
- Limited rom NANDA Noticeable and unusual intervention.
- Reluctant to bump, bend or twist
attempt Severe pain - Reposition frequently. Encourage - Lessens constant
movement Swelling use of trapeze, if possible. pressure on same areas
- Inability to Establish/adhere to regular turning and minimizes risk of
move schedule when client not able to skin breakdown. Use
purposefully Pathophysiology turn independently. of trapeze may reduce
within the risk of abrasions to
physical Accident elbows and heels.
environment
Fracture closed
Vital signs: complete displaced, collaborative
BP- 120/80 distal third, femur - Provide foam mattress, sheepskins, - bony prominences
PR- 82 flotation pads, or air mattress, as other than those
RR- 15 Restricted function of indicated. affected by the casting
T- 37 C right leg may suffer from
decreased circulation.
Tissue swelling, - Prepare for/assist with cast - Cutting or hinging the
bruising at the site of splitting (e.g., monovalve, cast allows the release
injury bivalve), or cut a window in cast, of pressure and
as indicated. provides access for
Gait and immobility wound and skin care.
problem