NURSING DIAGNOSIS: Impaired bone tissue perfusion related to continuation

infectious process.

EXPECTED OUTCOME: Patient’s condition of impaired tissue will improve as evidence

by decreased redness, swelling and pain.
ACTIONS/INTERVENTIONS RATIONALE

 Apply continuous or intermittent wet  To reduce intensity of

dressings. inflammation.
 Discourage rubbing and scratching
then provide gloves if necessary.  To prevent further injury and
 Provide medicated soaks in open delayed healing.
wound as ordered.
 To treat skin and tissue infections.

 Administer IV antibiotics as ordered

 To treat infection.

 encourage early ambulation, when

possible  To enhance venous return.

 Elevate the legs when sitting,

avoiding sharp angulation at the  To maximize tissue perfusion.

lower extremities.

 Discourage sitting/standing for long

 To prevent further injury.
periods, wearing constrictive
clothing, crossing legs.
NURSING DIAGNOSIS: Bone infection related to infection that has migrated to bone
tissue.

EXPECTED OUTCOME: Patient response to antibiotic therapy, as evidence by normal

WBC, negative wound culture findings.
ACTIONS/INTERVENTIONS RATIONALE

 Assess affected area for signs and
symptoms of infection.
 Assess lab values, especially WBC
and sedimentation rate.
 Assess bones scan finding.
 Assessment allows for care plan
modification as needed.
 To evaluate further abnormalities.
 To aid in establishing diagnosis.

 Obtain appropriate cultures and;

sensitivities; blood; aspirate from  Wound cultures are necessary to

bone abscess if present. identify causative agent.

 Administer IV antibiotics as ordered.  Aggressive antibiotic treatment is

the primary therapy.

 To prevent dehydration in febrile

 Provide fluids.
state.

 to prevent close contamination

 Ensure sterile technique during
dressing
NURSING DIAGNOSIS: Acute pain related to biological or chemical agent.

EXPECTED OUTCOME: Patient will state and carry out appropriate interventions for
pain relief. Patient will decrease amount and frequency of pain medication needed.
Patient will express feeling of comfort and relief from pain.
ACTIONS/INTERVENTIONS RATIONALE
 Assess patient’s signs and  Assessment allows for care plan
symptoms of pain and adminster
modification as needed.
medication as prescribed.
Monitored and record medications
effectiveness and adverse effect.
 Perform comfort measures to
 This measure reduce muscle tension
promote relaxation such as
massage and bathing, repostioning ort spasm, redistribute pressure on
and relaxation technique. body parts, and help patient focus on
non-pain- related subjects.
 To help patient focus and non-pain
 Plan activites with patient to
provide distraction such as related matters.
reading, crafts, television and visit.
 Help patient into a comfortable
 To reduce muscle tension and
position and use pillows to splint or
support painful areas as spasm and to redistribute pressure
appropriate. on body parts.

 To minimize or relieve pain.

 Apply heat and cold compress
NURSING DIAGNOSIS: Impaired skin integrity related to internal (somatic) and
external (environmental) factor.

EXPECTED OUTCOME: patient will exhibit improve or healed lesions or wound.

ACTIONS/INTERVENTIONS RATIONALE

 Inspect patient skin every shift,

 This provides evidence of the
describe and document skin
condition and report changes. effectiveness of the skin care
 Maintain proper enviromental regimen.
conditions including room
 Providing a comfortable environment
temperature and ventilation.
promote a sense of well being.
 Remind or warned patient not to
scrath or tampering with the wound  To avoid potential for infection.
or dressing.

 Position patient for comfort and

minimmal pressure. Change  This measures reduce pressure,
position every at least 2 hours.
promote circulation and avoid skin
breakdown.
 Explain the therapy to patient and
family members.
 To encourage compliance.
 NURSING DIAGNOSIS: Impaired physical mobility related to pain or discomfort.

EXPECTED OUTCOME: Patient will state relief from pain. Patient will begin to accept
limitations imposed by immobility and accompany lifestyle changes.
ACTIONS/INTERVENTIONS RATIONALE
 Encourage patient to verbalize  This aid the assessment of the
pain and discomfort. Observe for
location, quality and intensity of pain.
non-verbal cues of pain, including
favoring a body part and
grimacing.
 Perform the prescribed treatment
 To assess the effectiveness of the
regimen for the underlying
condition producive pain or treatment.
discomfort.
 Encourage patient in active  To increase the muscle tone of and
movements by using assistive
increase patient’s feeling and self-
devices.
 Implement ROM excersises every esteem.
shift after pain medication unless
medically contraindicated;
 This prevents joint contracture and
progress from passive as tolerated.
 Reposition patient every 2 hours muscle atrophy.
and provide meticoulous skin care.  To prevent skin breakdown.
 Encouraged patient to verbalize
feelings and concerns about his
 To reduce anxiety and promote
altered state of mobility.
compliance.