Name: Romualde S. Ison Gender: Male

Diagnosis: History of injury, sustaining lacerated wound left leg r/o sepsis Age: 48 years old

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:

“Mainit ang pakiramdam ko, tatlong araw na akong nilalagnat,” as verbalized by the patient.

Objective:

Increase in body temperature above the normal range (38.10 degree Celsius)

Body iswarm to touch

Skin redness especially on the infected area

Increased body temperature (Hyperthermia) related to effects of toxins (bacteremia).

Tetanus is a disease caused by a toxin produced by the bacteria called Clostridium tetani. This toxin can be found in soils heavy in manure or other organic material, particularly in tropical or humid regions of the hemisphere. Once the bacteria enters open wounds or cuts it generates spores, which in turn creates neurotoxins.

After 4 hours of nursing interventions, the patient’s body temperature will subside within the normal range.

Set the temperature a comfortable environment

Monitor body temperature every 2 hours

Provide adequate hydration or adequate drinking

Take action aseptic and antiseptic techniques in wound care.

Give cold compress if no seizures

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

After 4 hours of nursing interventions, the patient’s body temperature subsided within the normal range.

occur external stimuli.

Implement programs and antipyretic antibiotic treatment as ordered.

Collaborative laboratory examination of leukocytes.

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.

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

Name: Romualde S. Ison Gender: Male

Diagnosis: History of injury, sustaining lacerated wound left leg r/o sepsis Age: 48 years old

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:

”Hindi pa rin gumagaling yung sugat ko na nahiwa ng yero,” as verbalized by the patient.

Objective:

Disruption of skin surface at left leg

Localized erythema

(+) Pain

Swelling on the site of the wound

Impaired skin integrity related to mechanical factors.

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.

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

Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes.

Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.

Instructed family to maintain clean, dry clothes, preferably cotton fabric (any T-shirt).

Establishes comparative baseline providing opportunity for timely intervention.

Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin.

Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection.

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 non-metabolizing 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 low-oxygen (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.