Question

C. Develop a short term and long term goal for Leora Chang, who fell, fractured her hip, and had a hip pinning surgery 3 days ago.
D. Choose nursing interventions for Leora Chang (pt in scenario C) for the nursing diagnosis of impaired skin integrity related to surgical procedure AEB incisional wound on left hip.

Answer 1

Short term goal.

Mrs Leora Chang remains free from wound infection, acute pain and bleeding as evidenced by normal wbc counts, absence of fever, pain score of 0/10 and absence of active bleeding.

Long term goal.

Mrs leora chang will be able to achieve optimal level of Wellness as evidenced by herself performing activities of Daily living, participation in social gatherings and verbalization of restoration of preexisting health state.

Nursing interventions.

Assess characteristics of wound, including color, size (length, width, depth), drainage, and odor.

Performing daily surgical dressing under aseptic techniques.

Monitor daily vital signs and if needed send blood tests.

Assess patient’s nutritional status.

Position the patient every two hourly. Massage the bony prominence and provide back care every 8 hours.

Provide alpha mattresses to equalise the pressure on the body surface.

Assess for any neurvascular deficits. (5P's)

Educate the patient on home care management.