MIGUEL S.

DATIJAN III
ASSESSMENT

DIAGNOSIS

EAC 3RD YEAR BSN

(POTENTIAL PROBLEM)
INFERENCE

PLANNING

INTERVENTIO

RATIONALE

EVALUATION

N
Subjective:

Risk for

Hindi madalas
malinis yan.
Paminsan minsan
lang po. (pointing
towards the
Steinmann pin) as
verbalized by the
mother of the
patient.

infection

Objective:

Broken primary
defense due to
Steinmann pin
insertion
Messy and
humid
environment
Infrequent
cleaning at the
site of insertion
Frequent
scratching of the
affected area

related to
Steinmann
pin
insertion.

The client has

increased risk for
being invaded by
pathogenic
organisms because
of broken primary
defense due to
Steinmann pin
insertion.
Osteomyelitis
would likely to occur
if ever infection
takes place at the
site.

Short term goal:

Osteomyelitis is an
infection in a bone.
Infections can reach
a bone by traveling
through the
bloodstream or
spreading from
nearby tissue.
Osteomyelitis can
also begin in the
bone itself if an
injury exposes the
bone to germs.

will identify
interventions to
prevent/reduce risk
of infection as
evidenced by
positive feedbacks.

After 2 hours of
nurse patient
interaction and
intervention, the
patients mother
will:
Demonstrate
proper aseptic
technique in
cleaning the site of
the insertion.

1. Inspect the skin

for preexisting
irritation or breaks in
continuity.

2. Assess pin sites

and skin areas,
noting reports of
increased pain,
burning sensation,
presence of edema,
erythema, foul odor,
or drainage

1. Pins or wires
should not be
inserted through
skin infections,
rashes, or abrasions
(may lead to bone
infection).
2. May indicate
onset of local
infection or tissue
necrosis, which can
lead to
osteomyelitis

3. Provide sterile pin

or wound care
according to
protocol, and
exercise meticulous
handwashing.

3. May prevent
cross-contamination
and possibility of
infection.

4. Instruct patient
not to touch the
insertion sites.

4. Minimizes
opportunity for
contamination.

5. Monitor vital signs.

Note presence of
chills, fever, malaise,

5. Hypotension,
confusion may be
seen with gas

Long term goal:

After the shift , the
patient will be able
to:
Remain free from
infections as
evidenced by

Short term
goal:
After 2 hours of
nurse patient
interaction and
intervention, the
patients mother
was able to:
Demonstrate
proper aseptic
technique in
cleaning the site
of the insertion.
Identify
interventions to
prevent/reduce
risk of infection
as evidenced by
positive
feedbacks.
Goal Met
Long term goal:
After the shift ,
the patient was:
Free from

MIGUEL S. DATIJAN III

(POTENTIAL PROBLEM)
normal vital signs.

changes in
mentation.

Be free from skin

irritation
6. Investigate abrupt
onset of pain and
limitation of
movement with
localized edema and
erythema in injured
extremity.
7. Assess muscle
tone, reflexes, and
ability to speak.

8. Observe wounds
for formation of
bullae, crepitation,
bronze discoloration
of skin, frothy or
fruity-smelling
drainage.

EAC 3RD YEAR BSN

gangrene;
tachycardia, chills,
fever reflect
developing sepsis.

infections as
evidenced by
normal vital
signs.

6. May indicate
development of
osteomyelitis.

Free from skin

irritation as
verbalized by the
mother Mas
komportable na
sya ngayon at di
na nagkakamot

7. Muscle rigidity,
tonic spasms of jaw
muscles, and
dysphagia reflect
development of
tetanus.
8. Signs suggestive
of gas gangrene
infection.

9. Monitor lab and

diagnostic results
9. CBC: Anemia
may be noted with
osteomyelitis;
leukocytosis is
usually present with
infective processes.
ESR: Elevated in
osteomyelitis

MIGUEL S. DATIJAN III

(POTENTIAL PROBLEM)
10. Administer
medications; IV and
topical antibiotics

EAC 3RD YEAR BSN

GSCS: Identifies
infective organism
and effective
antimicrobial
agent(s)
10. Wide-spectrum
antibiotics may be
used
prophylactically or
may be geared
toward a specific
microorganism.