N Delayed Wound Recovery 2qhh
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Cues
Subjective: The client’s relative verbalized: -“Si mama kasi hindi na nakakagalaw simula nung nadala siya dito sa hospital dahil sa sakit niya.” -“Hindi ko rin naman masyado nalilinisan sugat niya kasi sa umaga lang ako nakakabisita. Wala ako sa gabi” -“Eh hindi rin kaya ni nanay linisin magisa
Nursing Diagnosis
Rationale
Goal and Objectives
Delayed wound recovery due to ineffective therapeutic regimen manageme nt and selfcare deficit as evidenced by impaired physical mobility.
Bedsores, more accurately called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure — usually from a bed or wheelchair — cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips
Goal: After the 8 hour shift of nursing interventions, the client will have faster wound recovery. Objectives: > Know the causes of her condition and follow steps on the proper therapeutic management.
Intervention s
Rationale
Evaluation
Goal Met.
1. Discuss pain control measures if needed. •
To help patient coop towards the proper pain management thus minimizing pain suffering and the ways of treating them.
2. Discuss Importance of adequate nutrition (especially fluids, proteins, vitamins B and C, iron and Calories). •
These provide patient information how nutrition could elevate his chances of a faster recovery and
yun. Gumalaw nga magisa nahihirapan siya eh” Objective: -Wound has foul smell -Patient cannot move by herself -Patient is bedridden for 3 months now. -Female; 66 y/o
and heels. Without adequate blood flow, the affected tissue dies. Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop bedsores. Bedsores can develop quickly, progress rapidly and are often difficult to heal.
wound healing. 3. Demonstrate appropriate positions for pressure relief. •
>Be confined for bed rest for about 2-3 weeks or more with controlled mobility on the affected part, that is towards recovery.
Enable client to minimize further skin trauma thus promoting wound healing and establish physical mobility.
4. Establish a turning or repositioning schedule •
This provide patient’s a guide towards a proper skin management technique minimizing more skin trauma and also giving the patient something to do thus promoting self-esteem. 5. Instruct in wound assessment and provide mechanism for documenting •
Necessary to gather more data concerning the patient’s condition thus identifying skin problems clearly and promoting selfesteem.
6. Emphasize principles of asepsis, especially hand washing and proper methods of handling used dressings. •
To avoid possible infection thus hindering the wound healing process.
7. Provide information about signs of wound infection and order complications to report. •
Elevate the chances of faster wound healing which is important towards avoiding further complications or early detections that requires immediate interventions.
8. Demonstrate wound care technique such as wound cleansing and dressing changing. •
To provide the patient on the correct procedures and techniques of wound caring.
9. Identify potential sources of skin trauma and means of avoidance. •
>Within 24 hours or less the patient can express feeling of relief and satisfaction upon the treatment of his condition.
>Monitor Vital signs every 4 hours.
>To istrate proper drugs needed ordered by the physician.
Necessary to anticipate future events thus avoiding unexpected complications or changes vital to the patient’s condition.
10. the use of appropriate defense mechanism. •
To asses patient upon the proper management of stress or depressions concerning on his condition.
11. Encourage verbalization of feelings, perceptions and fears. •
To evaluate patients perceptions upon his condition and giving us information towards assessing client problems.
12. Monitor and document vital signs.
•
To establish baseline data.
13. ister drugs according to the physician’s order while following the 10 right of istrating Drugs. •
For faster wound healing and to avoid errors during istration.
Subjective: The client’s relative verbalized: -“Si mama kasi hindi na nakakagalaw simula nung nadala siya dito sa hospital dahil sa sakit niya.” -“Hindi ko rin naman masyado nalilinisan sugat niya kasi sa umaga lang ako nakakabisita. Wala ako sa gabi” -“Eh hindi rin kaya ni nanay linisin magisa
Nursing Diagnosis
Rationale
Goal and Objectives
Delayed wound recovery due to ineffective therapeutic regimen manageme nt and selfcare deficit as evidenced by impaired physical mobility.
Bedsores, more accurately called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure — usually from a bed or wheelchair — cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips
Goal: After the 8 hour shift of nursing interventions, the client will have faster wound recovery. Objectives: > Know the causes of her condition and follow steps on the proper therapeutic management.
Intervention s
Rationale
Evaluation
Goal Met.
1. Discuss pain control measures if needed. •
To help patient coop towards the proper pain management thus minimizing pain suffering and the ways of treating them.
2. Discuss Importance of adequate nutrition (especially fluids, proteins, vitamins B and C, iron and Calories). •
These provide patient information how nutrition could elevate his chances of a faster recovery and
yun. Gumalaw nga magisa nahihirapan siya eh” Objective: -Wound has foul smell -Patient cannot move by herself -Patient is bedridden for 3 months now. -Female; 66 y/o
and heels. Without adequate blood flow, the affected tissue dies. Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop bedsores. Bedsores can develop quickly, progress rapidly and are often difficult to heal.
wound healing. 3. Demonstrate appropriate positions for pressure relief. •
>Be confined for bed rest for about 2-3 weeks or more with controlled mobility on the affected part, that is towards recovery.
Enable client to minimize further skin trauma thus promoting wound healing and establish physical mobility.
4. Establish a turning or repositioning schedule •
This provide patient’s a guide towards a proper skin management technique minimizing more skin trauma and also giving the patient something to do thus promoting self-esteem. 5. Instruct in wound assessment and provide mechanism for documenting •
Necessary to gather more data concerning the patient’s condition thus identifying skin problems clearly and promoting selfesteem.
6. Emphasize principles of asepsis, especially hand washing and proper methods of handling used dressings. •
To avoid possible infection thus hindering the wound healing process.
7. Provide information about signs of wound infection and order complications to report. •
Elevate the chances of faster wound healing which is important towards avoiding further complications or early detections that requires immediate interventions.
8. Demonstrate wound care technique such as wound cleansing and dressing changing. •
To provide the patient on the correct procedures and techniques of wound caring.
9. Identify potential sources of skin trauma and means of avoidance. •
>Within 24 hours or less the patient can express feeling of relief and satisfaction upon the treatment of his condition.
>Monitor Vital signs every 4 hours.
>To istrate proper drugs needed ordered by the physician.
Necessary to anticipate future events thus avoiding unexpected complications or changes vital to the patient’s condition.
10. the use of appropriate defense mechanism. •
To asses patient upon the proper management of stress or depressions concerning on his condition.
11. Encourage verbalization of feelings, perceptions and fears. •
To evaluate patients perceptions upon his condition and giving us information towards assessing client problems.
12. Monitor and document vital signs.
•
To establish baseline data.
13. ister drugs according to the physician’s order while following the 10 right of istrating Drugs. •
For faster wound healing and to avoid errors during istration.
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