NCP - PRIORITIZATION.docx

7/24/2019 NCP - PRIORITIZATION.docx

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NCP

PRIORITIZATION


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Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:

Ang sakit ngbinti ko asverbalized byt e !atientrates !ain as"#$% using!ain scale

&bjective:usesguardingbe avior 'it rigidmuscle toneon surroudinarea o(a((ected siteskinsurrounding(racture is'arm to

toucredness onand undera((ected siteslig tlytender totouc

Acute !ainrelated tobone(ragmentmovementasevidencedbycom!laintso( !ain

A(ter series o(nursingintervention) t e!atient 'ill beable to verbalizet at !ain asbeenrelieved#decreased* dis!lay rela+edmanner anddemonstrate useo( rela+ation skillsand diversionalactivities asindicated (orindividualsituation,

Assess (orlocation)intensity)-uality) and!reci!itating(actors

.ave t e!atient rate!ain intensityusing a !ainrating scale

Assess statuso( a((ectede+tremity)including !ain atinjury site)tenderness totouc )tem!erature)and edema/ove t e

!atient0se+tremitygently andcautiously

Administeranalgesics as

ordered on aregularsc edule* donot allo' !ainto get intense

Elevate

(racturede+tremity Assess (or

Identi(yingt ese 'illassist inaccuratediagnosisandtreatment*most!atients' oe+!erience(racturese+!eriencesome !ain)es!ecially'itmovementProvides amoreobjectivedescri!tion

o( t e levelo( !ain

Allo'sdetection o(early signso(neurovasculardys(unction

/ovemento( a((ectede+tremitycauses!ain* care(ulmovement!rovidessu!!ort (ort e !ain(ulareaDecreased!ain 'illim!rove t e!atient0sability to!artici!atein ! ysicalt era!yactivitiesre-uired (orim!rovedmobilityElevation

'ill reduceedema

A(ter series o( nursingintervention)t e !atient'as able toverbalize t at!ain as beenrelieved)dis!layedrela+edmanner anddemostrateduse o(rela+ationskills anddiversionalactivites)!atient alsorated !ain as2#$% using!ain scale,

a. acute pain

b. impaired physical mobility

c. impaired gas exchange

d. impaired skin Integrity

e. self care deficit

f. risk for peripheral neuro!ascular dysfunction

g. risk for trauma


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Assessment Diagnosis Planning Intervention Rationale

Subjective data:

na ulog ako!ababa sa agdankaya indi ako

ngayon makalakadas verbalized by t e!atient,

&bjective data:

3imitedrange o(motionDecreasedmuscle

strengtSlo'edmovementsSlig t (acialgrimace' enmoving3imitedability to dogross and(ine motorskills4unctionallevel: 2

Im!aired ! ysicalmobility related todiscom(ort and!ain secondary to(racture

A(ter series o(nursinginterventions) t e!atient 'illverbalize

'illingness to anddemonstrate!artici!ation inactivities) verbalizeunderstanding o(situation# risk(actors andindividualtreatment regimenand sa(etymeasures)maintain !ositiono( (unction andskin integrity asevidenced byabsence o(decubitus ulcers

5ote (actorsa((ectingcurrentsituation and!otential time

involved,

Assess degreeo( !ain)listening to t eclientdescri!tion

about mannerin ' ic !ainlimit mobility,

Assess client0sdevelo!mentallevel) motorskills) easeand ca!abilityo( movement)!osture andgait,Determine

istory o( (allsandrelatedness tocurrentsituation,

Encourage!artici!ationon diversionalor recreationalactivities,

Instruct !atient

Identi(ies!otentialim!airmentsanddetermines

ty!e o(interventionsneeded to!rovide (orclient0s sa(ety,

1o determine!resence o(c aracteristico( clientsuni-ueim!airmentand to guidec oice o(intervention,6lient may berestrictingactivitybecause o('eakness ordebilitation)actual injuryduring (all) or(rom!syc ologicaldistress t atcan !ersist

a(ter a (all,Provideso!!ortunity(or release o(energy)re(ocuses orsel( 7'ortand aids inreducingsocialisolation,


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in assisting inactive or!assive rangeo( motione+ercises o(a((ected anduna((ectede+tremities,

Provide (ootboard,

Assist 'it orencouragesel(7careactivities

Re!osition!eriodically,

Encourageincreased (luidIntake andnutritious(oods,

Increasesblood (lo' tomuscle andbone toim!rovemuscle tone)maintain jointmobility*

!reventcontracturesor atro! yand calciumresor!tion(rom disease, 8se(ul inmaintaining(unctional!osition o(e+tremities)

!reventingcom!licationsIm!rovemusclestrengt andcirculation)en ances!atientcontrol insituation and!romotessel(7 directed'ellness,Prevents orreducesincidence o(skincom!lication,Promotes'ell7beingandma+imizesenergy

!roduction,


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Assessment Diagnosis Planning intervention Rationale

Subjective:

lagi nalang masakityung ulo ko!agkagising ko asverbalized by t e

!atient,

&bjective:

6on(usionRestlessnessIrritabilityPale skincolor o( t e(eet6 est !ain

A9 level o(;2usually seenin (irst $@7

@ r?) ' icare closelyassociated'it (ractureses!ecially o(t e longbones and!elvis


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Subjective: Re!orts o( !ain

in t e a((ected or surroundingarea >le(t lo'erleg?

&bjective: Destruction o(

skin layers 9roken tibia in

t e lo'er le(te+tremity sticksout t roug t eskin,>6om!ound4racture?

Im!aired SkinIntegrity related totraumatic injurysecondary to o!en(racture asevidenced bydestruction o( skinlayers

A(ter series o(nursinginterventions) t e!atient 'ill verbalizerelie( o( discom(ort*Demonstratebe aviors#tec ni-uesto (acilitate ealingas indicated*maintain o!timalnutrition and ! ysical'ell7being*!artici!ate in!revention measuresand treatment!rogram andverbalize (eelings o(increased sel(7

esteem and ability tomanage situation,

Identi(yunderlyingcondition or!at ologyinvolved,Determineclient0s age anddevelo!mental(actors or abilityto care (or sel(,

Evaluate client0sskin care!ractices and

ygiene issues,

Determinenutritional statusand !otential (ordelayed ealing

Evaluate client'it im!airedcognition)develo!mental

delay) need (oror use o(restraints) long7term immobility,5ote !resence o( com!romisedmobility)sensation)vision) earing or s!eec ,

Assess blood

su!!ly andsensation o( skinsur(aces anda((ected area ona regular basis,

Revie'laboratoryresults !ertinentto causative

1o assesscausative orcontributing(actors,

1o determine trisks) sensitivityo( skin and leveo(res!onsivenessto !ainsensationsIne((ective

ygiene canresult in seriousskin im!airmentand discom(ort,

1o assess i(malnutritionis#could be acontributing(actor 1o identi(y risk(or injury andsa(etyre-uirements,

/ay im!actclient0s sel(7caas relates to skincare,

1o !rovide

com!arativebaseline ando!!ortunity (ortimelyintervention' en !roblemsare noted,

Albumin lesst an 2,Bcorrelates todecreased


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(actors,

Per(orm routineskin ins!ectionsdescribingobserved

c anges,Determinedegree andde!t o( injury or damage tointegumentarysystem,P otogra! t ea((ected area) asa!!ro!riate,

Determineclient0s level o(discom(ort,

Ascertainattitudes o(individual orsigni(icant ot ers

about condition,5otemisconce!tions,

Ins!ect skin on adaily basis)describingc aracteristicsand c anges int e a((ectedarea,Periodicallymeasure and! otogra! t ea((ected areaand observe (orcom!lications,

Avoid or limit useo( !lasticmaterial,Remove 'et and'rinkled7linens

'ound ealingand increased(re-uency o(!ressure ulcers,4or determiningt e need (orc ange o(interventions,

1o assess e+tento( involvement,

1o documentstatus and!rovide visualbaseline (or

(uturecom!arisons,1o clari(yinterventionneeds and!riorities,Identi(ies areasto be addressedin teac ing !lanand !otentialre(erral needs,

1o assist client'it correcting ominimizingcondition and!romote ealing

1o monitor!rogress o(

ealing,

/oisture!otentiatesbreakdo'n,


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!rom!tly,Re!osition clienton regularsc edule)involving client inreasons (or anddecisions abouttimes and

!ositions,Encourage earlyambulation ormobilization,

Provide o!timumnutrition)includingvitamins and!rotein,

Revie'im!ortance o(

ealt ) intactskin) as 'ell asmeasures tomaintain !ro!erskin (unctioning,

Assist t e clientor signi(icant

ot ers inunderstandingand (ollo'ingmedical regimenand develo!ing!rogram o(!reventive careand dailymaintenance,

1o en anceunderstandingand coo!eration

3essens constant!ressure on sameareas and minimizesrisk o( skinbreakdo'n,

Promotescirculation andreduces risksassociated 'itimmobility,1o !rovide a!ositive nitrogenbalance to aid inskin and tissue

ealing and tomaintain genera

good ealt ,1 eintegumentarysystem is t elargestmulti(unctionalorgan o( t ebody,En ancescommitment to!lan) o!timizing

outcomes,


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and discom(orton t e a((ectedlo'er e+tremity

&bjective:

Citmusculoskeletalim!airment onle(t lo'er leg

Im!aired! ysicalmobility

Environmentalbarrier*

mec anicalrestriction

skeletal tractionF

Sel( 6are De(icitin bat ing)dressing andtoileting related toim!airedimmobility asevidenced bytraction a!!lication

A(ter series o(nursinginterventions) t e!atient 'ill identi(yindividual areas o('eakness orneeds* verbalizekno'ledge o(

ealt care!ractices*demonstratetec ni-ues andli(estyle c anges tomeet sel(7careneeds* !er(ormsel(7care activities'it in level o( o'nability and identi(y!ersonal andcommunityresources t at can!rovideassistance,

5oteconcomitantmedical!roblems ore+istingconditions t at

may be (actors(or care,Identi(y degreeo( individualim!airment and(unctional levelaccording toscale,5ote ' et erde(icit istem!orary or!ermanent)s oulddecrease orincrease 'ittime,Provideaccurate andrelevantin(ormationregardingcurrent and(uture needs,Promote client0sor signi(icantot er0s!artici!ation in!roblemidenti(icationand desiredgoals anddecisionmaking,

Active listen

client0s andsigni(icantot er0sconcerns,

1o identi(ycausative orcontributing(actors,

1o assess degreeo( disability,

So t at client canincor!orate intosel(7care !lans' ile minimizing!roblems o(tenassociated 'itc ange,En ancescommitment to!lan) o!timizingoutcomes) andsu!!ortingrecovery and

ealt !romotion,

E+ ibits regard (orclient0s values andbelie(s) clari(iesbarriers to!artici!ation in sel(

care) !rovideso!!ortunity to 'orkon !roblem7solvingsolutions and to!rovideencouragement


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Practice and!romote s ort7term goalsetting andac ievement,

Ask client orsigni(icantot ers (or in!uton bat ing

abits orcultural bat ing!re(erences,&btain ygienesu!!lies (or

s!eci(ic activityto be !er(ormedand !lace inclient0s easyreac ,Provide (orade-uate'armt ,

Provide (or orassist 'itgroomingactivities on aroutine)consistentbasis,Encourage!artici!ation)guiding client0s

and t rougtasks) asindicated,

Ascertain t ata!!ro!riateclot ing isavailable,

Dress client or

and su!!ort,1o recognize t attoday0s success isas im!ortant asany long7term goal)acce!ting ability todo one t ing at atime and

conce!tualizationo( sel(7care in abroader sense,En ances sel(7esteem) ' ileres!ecting!ersonal andcultural!re(erences,

1o !rovide visualcues and (acilitatecom!letion o(activity,

6ertain individualsare !rone to

y!ot ermia andcan e+!erience

eva!orative coolingduring and a(terbat ing,E+!eriencing t enormal !rocess o(a task t rougestablis ed routineand guided!ractice (acilitateso!timal relearning,

6lot ing my needto be modi(ied (orclient0s !articularmedical conditionor ! ysicallimitations,


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assist 'itdressing) asindicated,

Encourage (ood

and (luidc oicesre(lectingindividual likesand abilitiesand t at meetnutritionalneeds,Provide !rivacy,

Assist 'itmani!ulation o(clot ing) i(needed,

Provide orassist 'it useo( assistivee-ui!ment,

Revie' sa(etyconcerns,/odi(y activitiesor environment,

Assist andsu!!ort (amily'it alternative!lacements asnecessary,

9e available (or discussion o((eelings aboutsituation,

6lient may needassistance in!utting on or takingo(( items o( clot ingor may re-uire!artial or com!leteassistance 'it(asteners,

1o ma+imize (oodintake,

1 at may beindicative o( need

(or !rom!t toileting,

1o decreaseincidence o((unctionalincontinencecaused by di((icultyremovingclot ing#under'ear,1o !romoteinde!endence and

sa(ety in sittingdo'n or arising(rom toilet or (oraiding elimination' en client isunable to go t ebat room,1o reduce risk o(injury and !romotesuccess(ulcommunity(unctioning,En anceslikeli ood o( (indingindividuallya!!ro!riatesituation to meetclient0s needs,Provideso!!ortunity (orclient#(amily to get(eelings out in t e


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o!en and begin to!roblem7solvesolutions asindicated,

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:/an id ang!akiramdamko sa binti koas verbalizedby t e !atient,&bjective:

Pallor color o( t e skinsurrounding (racturedareaSkinsurrounding a((ectedsite is coolto touc

Risk (or!eri! eralneurovascular dys(unctionrelated to!ossiblenervedamage dueto instabilityo( (racturedlimb

A(ter series o(nursingintervention)!atient 'ill be able toe+!erience nosevere !ain atinjury site*!atient0s!eri! eral !ulsesin is# er lo'erleg are !a!able*!atient0s lo'er legis 'arm 'itca!illary re(ill briskat G 2 secondsand !atient0slo'er leg remainsat normal color

Assessneurovascularstatus o( bote+tremitiesevery $7@

ours or asordered:!ulses)sensation)tem!erature)ca!illary re(ill)and movement

Assess (orsigns andsym!toms o(severe !ainunrelieved byusualanalgesic)diminis ed orabsent !ulses)

cool e+tremity)decreased orabsentsensation int e e+tremity)loss o( normalcolor) anddecreasedca!illary re(ill/onitor vitalsigns 'it

!articularattention toblood !ressurereadings

/aintain castand c eck (ortig tness

6 ecke+tremity (ore+cess edemaor tig tness*ask !atient

Establis es abaseline adt en detectsearly anycom!licationst at mayoccur due tocasting

8nrelenting!ain notrelieve byusualanalgesic isearly classicsign orcom!artmentsyndrome

A !atientmustmaintainsu((icientblood

!ressure inorder tomaintain!er(usion tot e a((ectede+tremitycom!artments6asts t atare too tig tmay lead to

com!artmentsyndrome bycausingundue!ressure ont ecom!artments o( t ee+tremityEdema t at isunrelievedt rougelevationcould lead to

A(ter o( nurintervn !atiedid noe+!eriany se!ain ainjury!atien!eri!!ulses

is#lo'er lare!al!ab!atienlo'er l'arm t'it aca!illa

re(ill seconand t!atienlo'er lremaiat norcolor)edems'ellinnoted


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Assessment Diagnosis Planning Intervention Rationale E


and discom(orton t e injuredle(t lo'ere+tremity,

&bjective: Cit Skeletal

traction on le(tlo'er e+tremity

Cit reducedmusclecoordination ont e a((ected le(tlo'er limb

Ceakness ont e injuredlo'er e+tremity

Risk (or 1raumarelated to use o(skeletal traction asevidenced by losso( skeletal integrityo( le(t lo'er leg

A(ter series o(nursinginterventions) t e!atient 'ill identi(yand correct!otential risk (actorsin t e environment*demonstratea!!ro!riate li(estylec anges to reducerisk o( injury*identi(y resourcesto assist in!romoting a sa(eenvironment*recognize need (orand seekassistance to

!revent accidentsor injuries,

Determine(actors relatedto individualsituation ande+tent o( risk (or trauma,

Ascertainkno'ledge o(sa(ety needsand injury!revention) andmotivation to!revent injury in

ome)community) and'ork setting,

Assessin(luence o(client0s li(estyleand stress,

Revie' istoryo( accidents)notingcircumstances,

Revie'diagnosticstudies andlaboratory tests(or im!airmentsor imbalances,Screen client (or

sa(etyconcerns, Assess (or andre!ort c angesin client0s(unctionalstatus, Per(ormt orougassessmentsregarding sa(etyissues ' en

In(luencessco!e andintensi(y o(interventions tomanage t reatto sa(ety,3ack o(a!!reciation o(signi(icance o(individual

azardsincreases risk o( traumatic injury,

1 at can im!air judgment andgreatly increaseclient0s !otential(or injury,6an !rovideclues (or client0srisk (orsubse-uentevents and!otential (oren ancedsa(ety by a

c ange in t e!eo!le orenvironmentinvolved,1 at may resultin or e+acerbateconditions sucas !at ological(racture,

4ailure to

accuratelyassess andintervene orre(er regardingt ese issuescan !lace t eclient atneedless riskand createsnegligenceissues (or t e


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!lanning (orclient disc arge,

/aintain bedrest or limb restas indicated,Provide su!!orto( joints above

and belo'(racture site)es!ecially ' enmoving andturning,Su!!ort (racturesite 'it !illo'sor (oldedblankets,/aintain neutral!osition o(

a((ected !art'it sandbags)s!lints)troc anter roll)and (ootboard,

Discussim!ortance o(sel(7monitoringo( conditions oremotions t atcan contributeto occurrence o( injury to sel(,

Identi(ycommunityresources,

ealt care!ractitioner,Providesstability)reducing!ossibility o(disturbingalignment and

muscle s!asms)' ic en ances

ealing,

Preventsunnecessarymovement anddisru!tion o(alignment,Pro!er!lacement o(

!illo's also can!revent!ressurede(ormities int e drying cast,6lient orsigni(icantot ers may beable to modi(yrisk t rougmonitoring o(actions or!ost!onemento( certainactions)es!eciallyduring times' en client islikely to be

ig ly stressed,1o assist 'itnecessarycorrections orim!rovementsand !urc ases,

NCP - PRIORITIZATION.docx

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