NURSING DIAGNOSIS

Acute pain related to puncture wound as manifested by sweating, pain and tingling sensation in
the puncture site with the scale of 6/10, redness and warm swollen in the puncture site, stiffness
on the right leg and restlessness.

INFERENCE

A deep wound that occurs due to sharp and pointed accidentally punctured the skin with a small
opening can be highly and easily infected because of the break in the skin and the puncture
object. Acute pain occurs to a puncture wound because the inflammatory process of the body,
wherein there is a release of the inflammatory mediators including bradykinin, prostaglandins
and histamine which causes the pain of inflammation.

GOAL

After 10-15 minutes of appropriate nursing interventions, the client will be able to report pain is
relieved or controlled as will be manifested by absence of tingling sensation, pain is relieved or
decreased and no stiffness on the right leg.

NURSING INTERVENTIONS RATIONALE

1. Provide nonpharmacologic comfort Promotes relaxation and helps refocus attention
measures such as massage, repositioning,
backrub, and diversional activities
2. Encourage use of stress management skills Enhances sense of control to pain and reduces
such as relaxation technique, visualization, stress
guided imagery, therapeutic touch
3. Encourage the client to be on bed rest To restrict the movement of the puncture site
4. Monitor the vital signs Vital signs are good indication of a disease
which might be causing the pain
5. Administer analgesics as prescribed To control and relieve pain in an acceptable
level

EVALUATION

Goal met. After 15 minutes of appropriate nursing interventions, the client was able to report
pain is relieved or controlled as manifested by absence of tingling sensation, pain is decreased
from 6/10 to 1/10, and no stiffness on the right leg.

NURSING DIAGNOSIS

Impaired physical mobility related to neuromuscular impairment as evidenced by discomfort,

poor posture and gait, decrease in range of motion on the lower extremities, and decrease in
gross motor skills.
INFERENCE

The patient was infected with Clostridium tetani which produces a Tetanus toxin or
tetanospasmin which causes neuromuscular impairment resulting to impaired physical mobility.
Neuromuscular impairment affects the nerve cells or neurons that sends and receives electrical
messages to and from the body which controls the voluntary muscles. Specifically,
neuromuscular impairments break down the communication of neurons between nervous system
and muscles thereby causing muscle aches, stiffness, and tingling sensation. (Lopez, 2011).
Motor coordination results in neuromuscular integrity. Consequently, lack of integrity in the
nervous and/or muscular system decrease the capacity to perform voluntary and productive
movements leading to impaired physical mobility (Costa, et. al. 2010).

GOAL

After 2-3 days of rendering appropriate nursing intervention, the client will be able to
demonstrate techniques or behaviors that enable resumption of activities and maintain or increase
strength and function of affected and/or compensatory body part as manifested by normal gait,
full range of motion on the lower extremities, and verbalization of "Ammuk ti pumayan tapnu
nalaklaka ken haan unay nasakit igaraw bagikon"

NURSING INTERVENTIONS RATIONALE

Provide a safe environment: bed rails up, These measures promote a safe, secure
bed in a down position, important items environment and may reduce risk for falls.
close by.
Establish measures to prevent skin his is to prevent skin breakdown, and the
breakdown and thrombophlebitis from compression devices promote increased
prolonged immobility: venous return to prevent venous stasis and
  possible thrombophlebitis in the legs.
 Clean, dry, and moisturize skin as
necessary.
 Use anti embolic stockings or sequential
compression devices if appropriate.
 Use pressure-relieving devices as
indicated (gel mattress).

Administer medications prior to activity as Reduces muscle and tissue stiffness and
needed for pain relief from uncontrolled tension, enabling client to be more active
spasms and facilitating participation.
Schedule treatments and care activities to Increases client’s strength and tolerance for
provide periods of uninterrupted rest. activity.
Perform ROM exercises consistently, Prevents progressively tightening scar tissue
initially passive, then active. and contractures, enhances maintenance of
 muscle and joint functioning, and reduces
loss of calcium from the bone.
Encourage family/SO support and assistance Enables family/SO to be active in client
with ROM exercises. care and provides more constant and
consistent therapy.
Promote and facilitate early ambulation These movements keep the patient as
when possible. Aid with each initial change: functionally working as possible. Early
dangling legs, sitting in chair, ambulation. mobility increases self-esteem about
reacquiring independence and reduces the
chance that debilitation will transpire.
Demonstrate use of standing aids and Promotes independence and enhances
mobility devices (e.g., walkers, strollers, safety.
cane, crutches) and have client/care provider
demonstrate knowledge about, and safe use
of device.
Let the patient accomplish tasks at his or her Healthcare providers and significant others
own pace. Do not hurry the patient. are often in a hurry and do more for patients
Encourage independent activity as able and than needed. Thereby slowing the patient’s
safe. recovery and reducing his or her
confidence.
Provide the patient of rest periods in Rest periods are essential to conserve
between activities. Consider energy-saving energy. The patient must learn and accept
techniques. his limitations.

EVALUATION

Goal met. After 2 days of rendering appropriate nursing interventions, the client was able to
demonstrate techniques or behaviors that enable resumption of activities and maintain or increase
strength and function of affected and/or compensatory body part as manifested by normal gait,
full range of motion on the lower extremities, and verbalization of "Ammuk ti pumayan tapnu
nalaklaka ken haan unay nasakit igaraw bagikon"

NURSING DIAGNOSIS

Impaired urinary elimination related to bladder outlet compression secondary to tetanus as

manifested by bladder distension, passes minimal amount of urine (2,750cc/day compared to
intake of 3,600cc/day), and pain in the hypogastric region.

INFERENCE

(mega is in the house) payting!

GOAL

After 4-8 hours of rendering appropriate nursing interventions, the client will be able to achieve
normal elimination pattern as will be manifested by relieved bladder, normal urine output
relative to the intake, and absence of pain in the hypogastric region and “nasayaat met lang iti
pinag-isbo kon, ken haan nga nasakit iti pus-ong kon,” as verbalized by the patient.

NURSING INTERVENTIONS RATIONALE

Encourage fluid intake up to 1,500-2,000 ml/ Sufficient hydration helps maintain renal
day (with cardiac tolerance), including function and urinary output. It also prevents
cranberry juice and avoiding caffeine infection and formation of urinary stones
Observe for cloudy or blood tinged urine, foul Signs of urinary tract or kidney infection that
odor. potentiate sepsis.
Instruct to perform proper and good perineal To reduce skin irritation and ascending
care and hand washing (if with urinary infection.
catheter)
Keep the bladder deflated by means of To prevent urinary retention and for
indwelling catheter. monitoring output.
Encourage to limit alcohol and caffeine The chemicals are known to be bladder
consumption. irritants and they can increase detrusor
overactivity.

EVALUATION

Goal met. After 8 hours of rendering appropriate nursing interventions, the client was able to
achieve normal elimination pattern as will be manifested by relieved bladder, normal urine
output relative to the intake, absence of pain in the hypogastric region and “nasayaat met lang iti
pinag-isbo kon, ken haan nga nasakit iti pus-ong kon,” as verbalized by the patient.