Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh] West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City I. Vital Information Name: E.D.D. Date of Interview: July 9, 2015 | 6:00 PM Age: 26 years old Informant: E.D.D. Sex: Male Relationship to patient: Patient himself Address: Brgy., Libo-on, Dingle, Iloilo Civil Status: Single Date and Time Admitted: June 23, 2015 |12:25 P.M. Chief Complaint: “Gasakit akon wala nga batiis kag wala gaayo.” Ward: OSSW Bed No.: 19 Allergies: Shrimp Paste Religious Affiliation: Roman Catholic Physician: Dr. J. Impression/Diagnosis: Osteomyelitis Left Thigh Pre-Op Diagnosis: Chronic Osteomyelitis Left Thigh Post-Op Diagnosis: Chronic Osteomyelitis Left Thigh Surgical Operation Performed: Debridement Curettage, Application of Gentamycin Beads Days Post-Op: 1 day
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Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
West Visayas State University COLLEGE OF NURSING
La Paz, Iloilo City
I. Vital Information
Name: E.D.D. Date of Interview: July 9, 2015 | 6:00 PM
Age: 26 years old Informant: E.D.D.
Sex: Male Relationship to patient: Patient himself
Address: Brgy., Libo-on, Dingle, Iloilo
Civil Status: Single
Date and Time Admitted: June 23, 2015 |12:25 P.M.
Chief Complaint: “Gasakit akon wala nga batiis kag wala gaayo.”
Ward: OSSW
Bed No.: 19
Allergies: Shrimp Paste
Religious Affiliation: Roman Catholic
Physician: Dr. J.
Impression/Diagnosis: Osteomyelitis Left Thigh
Pre-Op Diagnosis: Chronic Osteomyelitis Left Thigh
Post-Op Diagnosis: Chronic Osteomyelitis Left Thigh
Surgical Operation Performed: Debridement Curettage, Application of Gentamycin
Beads
Days Post-Op: 1 day
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
II. CLINICAL ASSESSMENT
II. A.: NURSING HISTORY
A. History of Present Illness
a. Usual Health Status
E.D.D. is a 28-year old farmer who lives with his father. Before being hospitalized, EDD
claimed that he has been consuming almost all of his time farming. He likes to eat vegetables
and does not like shrimp paste. He does not exercise as he devotes mostof time farming.
E.D.D. is an occasional alcoholic beverage drinker and doesn’t smoke. He takes Koi herbal
capsule 500mg OD everyday. He believes in quack doctors and “hilots”.
B. Chronologic History
E.D.D. is a 26 year old farmer who works every day since he was 16 years old.
10 months PTC, August 2014, while plowing the field bear footed, he noticed an
appearance of a boil characterized by a pus-filled red lump about the size of a pea on the left
lateral side of his left leg. He claimed that he just pinched it and continued on working. The next
day he went to the clinic because the area surrounding the boil became reddened and swollen.
The doctor prescribed him with cloxacillin sodium PO b.i.d. which he complied for a week and
fusidate sodium topical ointment t.i.d. which he claimed to use for 1 month. He claimed that he
continued working while taking the prescribed medications. The boil completely healed after a
month.
7 months PTC, on the first week of November 2014, after E.D.D. cut 5 large bamboos he
felt a throbbing pain, 3-4 inches in diameter, with pain scale of 8/10 starting from the left lateral
side of his thigh radiating to the upper and lower part of his thigh for five minutes. He claimed
that the affected area is warm to touch. He verbalized that he just rested and pain was relieved
with pain scale of 5/10. After 3 days, he experienced fever, with temperature unrecalled. He took
paracetamol 1 tab PO PRN and was relieved after 2 hours. The pain at his thigh with a pain scale
of 8/10 continued to recur lasting for 30 minutes to few hours. He just takes a rest until the pain
subsides. Two weeks after, E.D.D used an electric massager to relieve the pain at his thigh but
he verbalized that it became more swollen making it more painful with a pain scale of 9/10.
6 months PTC, December 2014, the pain became more recurrent. He was experiencing
the pain approximately 3-4 times throughout the day and is often precipitated by hearing loud
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
noises such as loud talking of a group of people. The pain radiates to his whole body with a pain
scale of 8 out of 10. Swelling of the thigh was noted and walking became difficult for him. They
went to an albularyo and he was given a “Lana” which he applied on his thigh three times a day.
E.D.D. claimed that there was no prompt relief of pain. After a week, they decided to consult a
doctor. He was prescribed with unrecalled antibitiotic PO b.i.d. for one week and pain medication
PRN. He claimed that he only took the antibiotic for 2 days due to increase in pain felt at his thigh
while taking the antibiotic. The pain scale was 9 out of 10. Instead he continued to use “lana”
three times a day stating that it somehow relieved the pain with pain scale of 7/10.
He continued to apply “lana” believing that it will collect the pus in the middle area that
will serve as the channel for the pus to be discharged which will lead to healing. With his
application of “lana”, the pain was alleviated, pain scale 5/10.
4 months PTC, February 2015, E.D.D. noticed a boil about a size of a 10 peso coin filled
with pus on the lower third aspect of his left thigh. He claimed that it was painful with a pain
scale of 7/10 but he just ignored it believing that this is the result of the application of “lana” to
the boil and just continued with his daily living. After 2 days, a discharge composed of pus and
minimal blood with no odor was noted. He wiped the discharge with cotton ball and claimed that
it was fully soaked. He then cleaned it and the surrounding area with “lana” thrice a day. Pain in
his thigh still became recurrent with a pain scale of 6 out of 10.
3 months PTC, March 2015, E.D.D. claimed that 2-3 inches proximal to the first protrusion,
a second boil was noted with a size of a one peso coin. He claimed that it is as painful as the first
one which has a pain scale of 6/10. The boil also breaks out with a discharge of pus and minimal
blood with no odor noted. He also cleaned it with “lana” three times a day. The pain was quite
relieved with pain scale of 5/10 but the discharges still continued.
4 days PTC, June 19, 2015, he decided to consult a doctor because there are still
discharges on both of the boil and the pain is still recurrent with pain scale of 6/10. The doctor
advised him to have an x-ray at WVSU-MC.
On the day of the confinement, June 23, 2015, the result of the x-ray came out. E.D.D
verbalized, “Kailangan ko na kuno mag pa admit kay asta na sa akon tul-an ang impeksyon”. The
doctor advised him to undergo an operation on his left thigh. Thus, this admission.
C. Review of Systems
A. General Health Survey
Pertinent Findings:
E.D.D’s patterns of ADLs changed because he had difficulty walking due to the pain he
experienced related to his condition.
B. Skin, hair, and nails
Pertinent findings:
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
Presence of two boils in the left lateral side of the thigh, approximately 2-3 inches away
from each other; tender to touch, presence of redness around the affected area with
presence of pus. E.D.D claimed to have allergies to “shrimp paste” (known locally as
“ginamos”). According to him, when he eats the said shrimp paste, he experiences itching
that begins in his abdomen and radiates throughout his body. E.D.D usually takes cetirizine
10 mg PO od to deal with his discomfort.
C. Head and Neck
Pertinent findings:
No relevant findings pertaining to the head and neck areas.
D. Eyes
Pertinent findings:
E.D.D does not use glasses or contacts and has never experienced problems with his
vision.
E. Ears
Pertinent findings:
E.D.D cleans his ears every 2-3 weeks. He has not experienced any problems with his
hearing and balance.
F. Nose and Sinuses
Pertinent findings:
No history of epistaxis or unusual discharges noted. Sinuses nontender.
G. Mouth and Throat
Pertinent findings:
Dental hygiene is done once everyday through brushing of teeth; absent: both first lower
molars, left upper second molar, right upper first molar; no dentures used.
H. Respiratory System
Pertinent findings:
E.D. D has past history of the common cold; breathing patterns are normal.
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
I. Cardiovascular System
Pertinent findings:
No history of chest pain, coldness of extremities, or palpitations. Usual blood pressure 110-
120/70-80 mmHg.
J. Breasts
Pertinent findings:
No lumps, pain, or discharges.
K. Gastrointestinal System
Pertinent findings:
E.D.D defecates once per day; no history of gastric ulcers noted.
L. Genitourinary System
Pertinent findings:
No history of UTI; voids 5-6 times per day as claimed.
M. Neurological System
Pertinent findings:
No history of neurologic alterations as claimed.
N. Musculoskeletal System
Pertinent findings:
Has difficulty performing ADLs since pain started on his left lower extremity; limps when
ambulating but can move on his own without assistance; described pain to be throbbing,
radiating from the lower and upper lateral thigh, pain scale of 6-8 in intensity, exacerbated
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
by noise and movement as claimed by E.D D ROM of both upper extremities and right lower
extremity 5/5. Left lower extremity 3/5.
II.B.: CLINICAL INSPECTION
Date and Time taken: July 9, 2015 | 7:00PM
II.B.1. Vital Signs:
T = 38.2 C/axilla PR = 76 beats/min.
BP = 120/70 mmHg RR = 20 breaths/min.
II.B.2. Height: 5 feet and 4 inches
II.B.3. Weight: 62 kilograms
II.B.4. PHYSICAL ASSESSMENT
General Appearance:
Lying in semifowler’s position; awake; calm; wearing navy blue jersey top and black shorts,
no foul smelling odor noted; with bandage covering his left leg from thigh to base of the toes
supported by a pillow underneath; oriented to person, place and time; with an IVF of D5LR x
KVO infusing well, attached to right metacarpal vein.
A. INTEGUMENTARY SYSTEM
Skin: Brown and uniform in color except in areas exposed to the sun; warm to touch; with scar
noted on the anterior side of his left elbow, approximately two inches above.
Hair: black in color; thick; evenly distributed; no infestations, lesions or masses noted.
Nails: Fingernails and toenails are neatly trimmed and clean; with translucent nail plate; pink
fingernail beds; pale toenail beds; no clubbing noted; capillary refill: less than 2 seconds.
B. NEURO-SENSORY SYSTEM
Eyes: eyebrows are black in color and symmetrically aligned; eyelashes are black, evenly
distributed and slightly curled outward, bulbar conjunctivae are transparent, palpebral
conjunctivae are pinkish in color, sclera is white, PERRLA.
Ears: Equal in size; auricles are symmetrically aligned; no tenderness or inflammation noted; no
lesions or discharges noted.
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
Nose: nasal septum midline; no flaring noted; no tenderness noted; sinuses are non-tender and
non-palpable
Cranial Nerve How Elicited Normal Response Actual Response
CN I: Olfactory
Ask the client to close eyes, occlude one nostril, and identify a
scented object that you are holding such as soap, coffee, or
vanilla. Repeat procedure for the other nostril.
Patient must be able to identify the scented object, with
eyes closed, the student nurse is holding with each
nostril occluded one at a time.
Intact; Patient was able to identify the aroma of coffee
diluted in water with both eyes closed.
CN II: Optic
Ask client to read a newspaper or
magazine paragraph to assess near vision.
Patient must be able to read the words in
the newspaper or magazine at a distance of 2 feet.
Intact; Able to identify and read all
the letters of a Snellen’s chart at a 2 feet distance; able to
see objects in periphery.
CN III: Oculomotor
CN IV: Trochlear
CN VI: Abducens
Perform corneal light reflex test. Hold a penlight approximately
12 inches from the client's face. Shine the light towards the
bridge of the nose while the client stares straight ahead. Note
the light reflected on the corneas.
To test direct pupil reaction, shine a light obliquely into one eye
and observe the pupillary reaction.
Test accommodation of pupils. Hold your finger or a pencil
about 12 to 15 inches from the client. Ask the client to focus on
your finger or pencil and to remain focus on it as you move it closer in toward the
eyes.
Patient must be able to move eyes with coordination; Eyes
must constrict as the light moves closer and dilates as the
light moves farther.
Intact; PERRLA; Patient was able to move eyes in unison
with coordinated movements
Test sensory function. Tell the client: "I am going to touch your
forehead, cheeks, and
Patient must be able to feel the stimulus of the cotton wisp as
it touches his face;
Intact; Blink reflex was present when examiner lightly
touched lateral sclera
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
CN V: Trigeminal chin with the sharp or dull sensation. Also tell
me where you feel it." Vary the sharp and dull stimulus in facial
areas and compare sides. Repeat test for light touch with a wisp
of cotton.
Test corneal reflex.
Ask the client to look away and up while you lightly touch the
cornea with a fine wisp of cotton. Repeat on the other side.
feel the difference and sensation of
sharp and dull
of the eye with wisp of cotton. Able to
determine light and deep sensation. Identified the area
touched with a wisp of cotton and the area touched with
the reflex hammer.
CN VII: Facial
Ask client to smile, frown and wrinkle
forehead, show teeth, puff out cheeks, purse lips, raise eyebrows,
close eyes tightly against resistance
Patient must be able to smile, frown and
wrinkle forehead, show teeth, puff out cheeks, purse lips,
raise eyebrows, and close eyes tightly against resistance.
Intact; able to keep mouth open while
the examiner tries to close it. Able to smile, frown, wrinkle
forehead, show teeth, puff out cheeks, purse lips,
raise eyebrows, close eyes tightly and opens mouth.
CN VIII: Vestibulocochlear
Rinne Test: Strike a tuning fork and place
the base of the fork on the client's mastoid process. Ask the client
to tell you when the sound is no longer heard. Move the
prongs of the tuning fork to the front of the external auditory canal. Ask the client to
tell you if the sound is audible after the fork is moved.
Whisper a two-syllable word at a distance of
2 feet unto the client's ears and let her repeat the whispered word.
Air conduction should be longer than bone
conduction (positive Rinne).
Patient must hear the two-syllable word spoken at a distance
of 2 feet on both ears.
Intact; Bone conduction time is
longer than the air conduction time (negative Rinne).
Patient was able to hear the spoken
word, "Lapis", on both ears at a distance of 2 feet
and was able to hear the vibrations of the tuning fork.
CN X: Vagus
Test gag reflex by touching the posterior
pharynx by the tongue depressor. Warn the client that you are
going to do this and
Gag reflex must be present.
Intact; (+) gag reflex.
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
that the test may feel a little uncomfortable
CN XI: Accessory
Ask client to shrug shoulders against
resistance.
Ask the client to turn
the head against resistance first to the right then to the left.
Patient must be able to shrug shoulders
and turn head to the right and left against resistance.
Intact; able to shrug shoulders and turn
head from side to side against pressure, no pain
noted upon doing so.
CN XII: Hypoglossal
Ask client to protrude tongue, move it to
each side against the resistance of a tongue
Patient must be able to protrude tongue,
move it to each side against the resistance of the
tongue
Intact; Able to protrude tongue at
midline, pain felt while protruding tongue and move it
A single unit of whole blood contains 450mL of blood and 50mL of an anticoagulant. A
unit of whole blood can be processed and dispensed for administration. However, it is more
appropriate, economical, and practical to separate that unit of whole blood into its primary
components: RBCs, platelets, and plasma. Each component must be processed and stored
differently to maximize the longevity of the viable cells and factors within it; each individual blood
component has a different storage life. PRBCs are stored at 4˚C.
It is important also to accurately determine the blood type. More than 200 antigens have
been identified on the surface of RBC membranes. Of these, the most important for safe
transfusion are the ABO and Rh systems. The ABO system identifies which sugars are present on
the membrane of an individual's RBCs: A, B, both A and B, or neither A nor B (type O). To prevent
a significant reaction, the same type of RBCs should be transfused.
The Rh antigen (also called D) is present on the surface of RBCs in 85% of the population
(Rh positive). Those who lack the D antigen are called Rh-negative. RBCs are routinely tested for
the D antigen as well as ABO. Patients should receive PRBCs with a compatible Rh type.
(Source: Brunner & Suddarth's Textbook of Medical-Surgical Nursing; Page 923)
Blood type "A" Rh (+)
The Rh antigen is present on
the surface of RBCs in 85% of
the population (Rh positive).
Those who lack the D antigen
are called Rh-negative. RBCs
are routinely tested for the D
antigen as well as ABO. Patients
should receive PRBCs with a
compatible Rh type.
(Source: Brunner & Suddarth's
Textbook of Medical-Surgical
Nursing; Page 926)
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
Blood type Amount| Serial Number
A 545| T 5700-004546-1
A 278| T 500-014518-1
A 528| 004081-2
Remarks: Compatible
8. Xray
An X-ray is a quick, painless test that produces images of the structures inside your body —
particularly your bones.
X-ray beams pass through your body, and they are absorbed in different amounts depending on
the density of the material they pass through. Dense materials, such as bone and metal, show
up as white on X-rays. The air in your lungs shows up as black. Fat and muscle appear as
shades of gray.
For some types of X-ray tests, a contrast medium — such as iodine or barium — is introduced
into your body to provide greater detail on the images.
Purpose:
Radiologic assessment of chronic osteomyelitis is performed for the following reasons: (1) to
evaluate bone involvement (eg, the extent of active intramedullary infection or abscess
superimposed on areas of necrosis, sequestrum and fibrosis) and (2) to identify soft tissue
involvement (areas of cellulitis, abscess, and sinus tracts).
Date: 6/23/15
Xray requested: Left Thigh APL
Impression:
- Negative for fracture and/or dislocation.
- Sclerosing osteomyelitis, considered.
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
III. TEXTBOOK DISCUSSION
Definition
Osteomyelitis
Infection in bony tissue can be a severe and difficult-to-treat problem. Bone infection can result
in chronic recurrence of infection, loss of function and mobility, amputation, and even death.
Chronic Osteomyelitis
Inadequate care management results when the treatment period it too short or when the
treatment is delayed or inappropriate. About half of cases of chronic osteomyelitis are caused
by gram-negative bacteria. Although bacteria are the most common causes of osteomyelitis,
viruses and fungal organisms also may cause infection
Signs and Symptoms
Acute Osteomyelitis
Found in Text Book Manifested by the Patient
Fever > 38ºC (+) Nov. 2014
Swelling (+) Nov. 2014
Erythema (-)
Tenderness (+) Nov. 2014
Bone pain (+) Nov. 2014
Chills (-)
Rapid Pulse (+) Nov. 2014
General Malaise (+) Nov. 2014
Chronic Osteomyelitis
Found in Text Book Manifested by the Patient
Ulceration of the skin (+) Feb. 2014
Sinus tract formation (+) Feb. 2014
Localized pain (+) Dec. 2014
Drainage from the affected area (+) Feb. 2014
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
Management
Bone scan is done to detect osteomyelitis through injection of bone-seeking radioisotope. Bone scans are used in conjunction with bone biopsy for a definitive diagnosis.
Erythrocyte sedimentation rate (ESR): the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the
presence or absence of bone infection. Magnetic resonance imaging (MRI) with gadolinium is the imaging modality of choice,
particularly for detection of early osteomyelitis and associated soft-tissue disease (A-II). Erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level may be helpful to guide response to therapy (B-III) (1). MRI is useful for determining location and extent of
involvement of the bone infection. IV antibiotic therapy begins as soon as the culture specimens are obtained, based on the
assumption that infection results from a staphylococcal organism that is sensitive to a penicillin or cephalosporin. IV antibiotic therapy continues for 3 to 6 weeks. After the infection appears to be controlled, the antibiotic may be administered orally for up to 3 months.
Prophylactic treatment with the bead pouch technique has been suggested in open fractures to reduce the risk of infection, with systemic antibiotics supplemented with antibiotic beads compared to using systemic antibiotics alone. Beads have proved to be more effective than
solid antibiotic-loaded cement plugs in the treatment of osteomyelitis. Oral quinolones are often used in adults for gram-negative organisms. Quinolones have
excellent oral absorption and may be used as soon as patient is able to take them. Rifampin has an optimal intercellular concentration and a good sensitivity profile for methicillin-
resistant staphylococci. It is used in combination with cell wall active antibiotics to achieve synergistic killing and to avoid rapid emergence of resistant strains.
Surgical management If the infection is chronic and does not respond to antibiotic therapy, surgical débridement is
indicated. Because surgical débridement weakens the bone, internal fixation or external supportive devices may be needed to stabilize or support the bone to prevent pathologic fracture.
The Ilizarov method involves the use of a tissue-sparing, cortical osteotomy-osteoclasis technique that preserves the osteogenic elements in the limb. To create a preliminary callus
that can be lengthened, Ilizarov advocated a delay of several days before initiating distraction. A high-frequency, small-step distraction rhythm permits regeneration of good-quality bone and less soft-tissue complications such as nerve and vessel injury. An advantage of using this
procedure is that it minimizes the prevalence of nonunion and thus further bone grafting by producing good-quality bone formation.
A sequestrectomy (removal of enough involucrum to enable the surgeon to remove the sequestrum) is performed. In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer
(saucerization). All dead, infected bone and cartilage must be removed before permanent healing can occur. A closed suction irrigation system may be used to remove debris. Wound irrigation using sterile
physiologic saline solution may be performed for 7 to 8 days. The wound is either closed tightly to obliterate the dead space or packed and closed later by granulation or possibly by grafting.
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
Nursing Management - The affected part may be immobilized with a splint to decrease pain and muscle spasm. The nurse monitors the neurovascular status of the affected extremity. Elevation reduces swelling and associated discomfort.
- The joints above and below the affected part should be gently moved through their range of motion. The nurse encourages full participation in ADLs within the physical limitations to
promote general well-being. - The nurse monitors the patient’s response to antibiotic therapy and observes the IV access
site for evidence of phlebitis, infection, or infiltration. - With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of
superinfection (eg, loose or foul-smelling stools). - If surgery is necessary, the nurse takes measures to ensure adequate circulation to the affected area (wound suction to prevent fluid accumulation, elevation of the area to promote
venous drainage, avoidance of pressure on the grafted area), to maintain needed immobility, and to ensure the patient’s adherence to weight-bearing restrictions.
- The nurse changes dressings using aseptic technique to promote healing and to prevent cross-contamination.
- The nurse continues to monitor the general health and nutrition of the patient. A diet high in protein promotes a positive nitrogen balance and healing. The nurse encourages adequate hydration as well.
- Encourage the patient to verbalize his concerns about his disorder.
- Encourage the patient to perform as much self-care as his conditions allows.
- Provide thorough skin care and complete cast care.
- Administer prescribed analgesics for pain.
- Watch for signs of pressure ulcer formation.
- Look for sudden malpositioning of the affected limb, which may indicate fracture.
- Explain all the test and treatment procedures.
Nursing Competency Appraisal – DREAM TEAM - Group 2 Section B – CLASS 2016 [Chronic Osteomyelitis Left Thigh]
PROBLEM LIST
1. Acute pain related to surgical procedure
2. Impaired physical mobility related to surgical procedure and musculoskeletal impairment
3. Constipation related to insufficient physical mobility
4. Risk for impaired peripheral tissue perfusion
5. Risk for infection related surgical incision
6. Risk for impaired skin integrity related to surgical procedure
7. Ineffective Role Performance related to situational crisis