C.

NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Risk for After 1 week of 1. Inspect the 1. Pins or wires After 1 week of
infection nursing skin for should not be nursing
------------------------- related to interventions the preexisting inserted through interventions the
skeletal patient will: irritation or skin infections, patient:
OBJECTIVE: traction (halo- 1. Identify breaks in rashes, or 1. Is able to
traction) intervention continuity. abrasions (may identify
(+) presence of s to 2. Assess pin lead to bone intervention
portal of entry (pin prevent/red sites and skin infection). s to
site insertion of uce risk of areas, noting 2. May indicate the prevent/red
halo-traction) infection reports of onset of local uce risk of
2. Be free of increased pain, infection or infection
purulent burning tissue necrosis, 2. is free of
drainage or sensation, which can lead purulent
erythema presence of to osteomyelitis. drainage or
and be edema, 3. May prevent erythema
afebrile. erythema, foul cross- and be
odor, or contamination afebrile.
drainage. and possibility
3. Provide sterile of infection.
pin or wound 4. Minimizes
care according opportunity for
to protocol, contamination.
and exercise 5. Damp, soiled
meticulous casts can
handwashing. promote the
4. Instruct patient growth of
not to touch bacteria.
the insertion 6. Muscle rigidity,
sites. tonic spasms of
5. Line perineal jaw muscles, and
cast edges dysphagia reflect
with plastic the development
C. NCP

wrap. of tetanus.
6. Assess muscle 7. Hypotension,
tone, reflexes, confusion may
and ability to be seen with gas
speak. gangrene;
7. Monitor vital tachycardia,
signs. Note chills, fever
presence of reflect
chills, fever, developing
malaise, sepsis.
changes in Monitor laboratory and
mentation. diagnostic studies:
Monitor laboratory  Anemia may be
and diagnostic noted with
studies: osteomyelitis;
 Complete leukocytosis is
Blood Count usually present
(CBC) with infective
 ESR processes.
 Elevated in
osteomyelitis.