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Outline of Nursing Management

1) GOAL- To relieve acute pain related to trauma Dependent: To administer analgesics as ordered.

Independent: Perform comprehensive assessment each time pain occurs. Provide back rub or position the client to a comfortable position. Instruct in the use of relaxation techniques such as pursed lip breathing. Encourage diversionary activities such as socializing with others. Create a quiet and non-disruptive environment Encourage adequate rest periods.

2) GOAL- To minimize risk for infection related to impaired skin integrity Independent: Monitor vital signs especially temperature. Promote thorough hand washing by caregiver and patient. Provide meticulous skin,oral, perineal care. Encourage frequent position changes/ambulation,coughing and DBEs. Promote adequate fluid intake.

Dependent: Administer topical antiseptics,systemic antibiotics as ordered.

Collaborative: Obtain specimen for Culture and Sensitivity as indicated.

3) GOAL- To correct deficiency in fluid volume related to hemorrhage Independent: Assess vital signs Estimate traumatic or procedural fluid loss and note possible routes of insensible losses. Note complaints and physical signs associated with dehydration like weakness,dry membranes,delayed capillary refill, poor skin turgor, headache. Change position frequently Discuss factors related to occurrence and ways client/SO can prevent dehydration Teach SO and PT how to monitor I/O

Dependent: Administer medications e.g. antiemetics or antidiarrheals.

Collaborative: Establish 24 hour fluid replacement needs and routes to be used. Assist in blood transfusion as ordered.

DISCHARGE PLANNING MEDICATIONS Instruct patient to take medication on time as ordered. Instructed S.O. to monitor patient medication Teach patient the importance of post operative exercise. Teach patient that activity stimulates circulation and deep breathing speeds recovery. Teach patient passive ROM exercises. Treat wounds aseptically with povidone antiseptic and cover with sterile gauze. Encourage patient to practice proper handwashing to prevent infection. Teach patient the importance of returning promptly to scheduled follow up check-ups. Instruct patient to eat foods high in protein and Vit C such as meat and fruits to speed up healing/recovery process. Encourage patient to pray regularly to God and ask guidance to avoid from being harmed.

EXERCISE

TREATMENT HEALTH TEACHING OUT-PATIENT DIET

SPIRITUAL