Nursing Process Worksheet
The nursing diagnosis for this patient includes:
(A and B). Alteration in skin integrity r/t surgery secondary to left femur fracture.
(C). Alteration in comfort; pain r/t postoperative status and fracture.
(D). Immobility r/t prolonged bedrest.
(E). Potential for impaired gas exchange r/t prolonged bedrest.
(F). Alteration in elimination; constipation r/t prolonged immobility.
(G). Potential for infection r/t post-operative status.
|1. Alt in skin Integrity||Highly likelihood of a skin tearing after 18 feet falls onto concrete. Wound incision during open reduction and internal fixation on left femur fracture. Staples on wound. Drainage on the end of the incision. On bedrest.|
|2. Alt in comfort, pain||Left femur fracture and surgery. Wound incision closed with staples and still draining serosanguinous exudates. Lot of pain in right arm and the incision. Discomfort during dressing changes. Vitals every 4 hours.|
|3. Immobility||Left femur fracture. Wound incision undergoing healing process and still draining may also affect immobility. Pain in the right arm and incision site.|
|4. Impaired gas exchange||Lungs have fine crackles at the bases. Respiration rate of 24 breaths per minute while resting in the bed. Low quality breathing due to bed rest.|
|5. Alt in elimination||Immobile due to left femur fracture can cause difficulty going to bathroom. In pain; rated as 5 in the scale of 10. Diet just changed to regular type, so expecting changes in eliminating habits and other aspects.|
|6. Potential for infection||Wound draining exudates. Dressing changes could bring in new infections. Possible weakened immune system due to his post operative status.|
|1. for Nsg dx alt in skin integrity:-Patient’s wound will be free of drainage and stay clean.-The staples around the incision will remain intact until the physician orders otherwise.-Prevent developing pressure ulcer while on bed rest.-Patient will intake proper fluids and nutrition.||-Dressing changes will be done every done and more as needed.-Nurses and other workers will touch the staples only when needed to.-Reposition the patient q2h and use draw sheets to turn and boost up.-Nurse will observe his I&O. Offer extra snacks and fluids if he prefer also.||-Dressings absorb all the exudates and changing them keeps the wound clean.-The staples keep incision closed and help speed up the healing process. Its removal needs doctor’s approval.-Reposition relieves the pressure and draw sheets prevent sheering.-Wound healing can be affected in the absence of proper nutrition and hydration.|
|2. for Nsg dx alt in comfort, pain:-Discomfort from left femur fracture will be kept to minimum.-Exudates won’t reach outside the wound area or on any healthy skin.-Pain medications will be administered in a timely manner and as patient requests (PRN).-Reduce the frequency of vital signs as deemed possible.||-While doing ADLs, patient’s left thigh will not be moved.-Dressing changes (packing) every shift and more as needed.-Patient will be educated about the pain medications physician ordered for him – time, dose, frequency and route.-Baseline vital signs will be established and patient’s vital signs sheet will be available for all nurses to view.||-Moving the fracture body parts could be discomforting.– Discomfort feeling of drainage on the skin can be easily contained by frequent dressing changes that will soak in all the exudates.-Patients who are better educated about their pain medications are more likely to request and use them properly.-Frequent vital signs can be discomforting but it can be reduced by establishing a good baseline and sharing the data among nurses so every nurses won’t have to take one for their own in a small time period.|
|3. for Nsg dx of immobility:-Patient will get out of the bed and start walking while considering his femur fracture.-Prevent wound draining excessively due to moving around.-Pain due to physical activity will be controlled.||-Nurses will follow the PT’s recommendations about routine and assistive devices to walk the patient.-Change dressings before and after physical activities involving the wound site.-Administer pain medications before and after the ambulation and other physical activities.||-Femur fracture shouldn’t be preventing patient from walking completely; assistive devices such as crutches could be used.-Cleaning the wound site before and after the physical activity to the wound site will prevent excessive drainage and accumulations.-Pain medications will make it easier for the patient to perform physical activities.|
|4. for Nsg dx of impaired gas exchange:-Lung sound will be clear to auscultation with no crackles.-Patient’s respiration rate will be below 20 breaths per minute within a week.-Prevent acquiring pneumonia while on bed rest due to aspiration.-Treat tachypnea as soon as possible.||-Patient will have his head of the bed at 45 degree angle and taught coughing effectively.-Patient will be taught breathing techniques of slow inspiration and expiration.-Assist patient sit up while eating meals.-Assess oxygen saturation and administer O2 accordingly.||-Crackles are often due to deposition of respiratory secretion.-Patient is hyperventilating and thus need to learn how to breathe slowly and effectively.-Eating in the bed with head low position puts patients at risk for aspirating food the lungs.-If the O2 saturation is low and patient having tachypnea, O2 administration can help.|
|5. for Nsg dx of alteration in elimination:-Patient will be able to eliminate with dignity even when on total bed rest days.-Patient will use bathroom as soon as he is placed on OOB therapy.-Dietary changes will be reflected in changes in elimination.||-Assist patient with urinal and bed pans.-Assist patient with the bathroom and let him do most of the tasks independently.-Educate patient about the changes in elimination aspects due to dietary changes.||-Bed pans and urinals are good alternatives to bathroom when not able to go to the toilet.-Patients should be allowed to do their own personal hygiene and elimination task when possible.-Diet and elimination move side by side; some patients might not know be thinking of that.|
|6. for Nsg dx of potential for infection:-Healthy skin around wound area will remain healthy.-Prevent presenting infections to the wound during dressing changes.-Strengthen patient’s immune system to combat post-op weakening.-Catch the infection as soon as the patient catches one||-Contain wound drainages from overflowing to the nearby areas.– Clean and/or sterile technique to change dressings.-Educate, offer and assist with good hygiene and nutrition.– Monitor vital signs for any out of baseline/range data.||-Containing the exudates before it overflows is the best way to protect the nearby skin areas.-Wound dressing change is an invasive procedure and is very susceptible to infection; so good clean/sterile technique should be applied.-Post-op patients have weakened immune system; therefore, they need immune strengthening through good nutrition and cleanliness.– Vital signs when out of range could mean inflammation and infections, which are best treated when caught early.|
Resources used: Textbook of Basic Nursing by Caroline Bunker Rosdahl and Mary T. Kowalski & Nursing Fundamentals by Rick Daniels.