__GW IS A 56 YEAR OLD MALE, ADMITTED FROM A NURSING HOME 3/25/14. HE WAS COMPLAINING OF LEFT LEG PAIN OF HIS INFECTED LEG AND WAS DIAGNOSED WITH CELLUTITIS AND INFECTED ULCER WOUND OF THE LEFT LEG. HE IS A FULL CODE, NKA, AND AO X 3. HE IS ON CONTACT PRECAUTION. HE HAS A HISTORYOF MRSA NARES FROM FEBRUARY, WITH A PRESENTCULTURE STILL PENDING.
OTHER PAST HISTORY INCLUDES SCHIZO-AFFECTIVE DISORDER, DEPRESSION, DVT RIGHT FEMORAL, HIP REPLACEMENT, STASIS ULCER DRUG ABUSE, AND ALCOHOL ABUSE. HE IS NPO, SCHEDULED TO GO INTO SURGERY FOR WOUND DEBRIDEMENT OF THE LEG LEFT/ANKLE. HE HAS A 22G RIGHT OUTER FOREARM IV ACCESS, BEING TREATED WITH 0.
45 NS AT 40CC/HR. HE IS BEING TREATED WITHPIPERACILLIN/TAZOB (ZOSYN) 3. 375G Q6 IVP,AND VANCOMYCIN 1. 0MG Q12 IVP. PATIENT HAS A TENDENCY TO ACT SEXUALLY INAPPROPRIATE, YELL, AND IS UNCOOPERATIVE AT TIMES. STAY CALM, AND FIRMLY ASK TO CHANGE CONVERSATION. HE IS ABLE TO TOLERATE MOST ACTIVITY I. E. SITTING UP IN CHAIR, INDEPENDENT FEEDING, AND USES URINAL. DUE TO DECREASED MOVEMENT, PT IS ON PRESSURE REDUCTION AIR MATTRESS, AND SCD POSTSURGERY.
HE REFUSED AM CARE, AND REUSED STRESSTEST, STATING, “WHY DO I NEED A STRESSTEST, I AM NOT HERE FOR MY HEART! ” FOLLOWUP WITH EDUCATION ON PERSONAL HYGIENE, SKIN CARE, AND EDUCATIONON CIRCULATION PROBLEMS AND HOW THE HEARTIS GREATAFFECTED. FOLLOW NURSING CARE OF HIS WOUND POST SURGERY:CLEANSE WITH NS, APPLY BACTROBAN OINTMENT, APPLY VASELINE GAUZE, COVER WITH4X4, AND THEN WRAP WITHKERLIX. PSYCHOSOCIAL ASSESSMENT: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Student Name: ____ Date: ____3/27/14__________ 2 _____________________________________________________________________________________________
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DIAGNOSTIC TESTS PRESCRIPTIONS/ORDERS Item Rea son (explain specifically why ordered for this patient) Diet NPO for surgery I/O VS Activity As tolerated PRN due to pain of left leg. Acc u-c heck Foley NG tube PEG/PEJ tube Chest tube Tr a c h Suctioning Dra i ns Ostomy Dressing change &/or wound care Routine dressing care for ulcer/cellulitis Trea t ments Special Equipment SCD compression Other PRO STAT 64 SUPPLEMENT FOR INSUFFICENENT PROTEIN/BID Test Date Result Reason(s) Needed and if abnormal- why?
CXR 3/25/1 4 Routine EKG 3/25/1 4 Routine CT Stress test 3/26/1 4 refused MRSA Nasal 3/25/1 4 In progress Hx of MRSA nares Wound culture 3/25/1 4 Leg/foot Gram negative rod Infected leg Therapie s Activity/Tx Reason(s) Needed Resp. PT OT Speech Other Student Name: ____ Date: ____3/27/14__________ 3 IV ACCESS TYPE: 22G IV SITE: RIGHT OUTER FOREARM FLUID/RATE: 0. 45 NS 40 ML/HR Reason(s) for IV access: Patient is on NPO status, so fluid is needed for supplementation.
Also IV antibiotics are needed to treat infected wound. 1. 0-2. 0 11-12. 5 sec. 30-40 sec. 150-400 M/mm3 5-10M/mm3 Student Name: ____ Date: ____3/27/14__________ 4 Abnormal Labs: Please document abnormal labs here. Add more lines if needed. Labs only as indicated indicated indicated indicated Result Normal Labs only as indicated Result Normal NA 142 WNL 135-145mEq/L Albumin 3. 3 LOW 3. 5-5g m/ d l K4. 0 WNL 3. 5-5. 0mEq/L Total Protein 7.
0 WNL 6. 4-8. 3 gm/dl Cl 106 WNL 98-106mEq/L Hgb 13. 5 WNL 12-18m/ d l CO2 26 WNL 22-26mmol/L Hct 38. 2 WNL 37-52m/d l Calc i um 8. 6 WNL 8. 5-10. 2mg/dl Pla telets 259 WNL 150-400 M/MM3 Mag 1. 9 WNL 1. 3-2. 1mEq/L PT 10. 1 11-12. 5 sec Phos 3. 8 WNL 2. 4-4. 1mg/dl PTT 28. 2 WNL 25-35 sec BUN 16 WNL 7-20mg/dl D. Bilirubin 0. 1 WNL 0. 1-0. 3 mg/dl Creatinine 0. 7 WNL 0. 6-1. 2mg/dl T. Bilirubin 0. 4 WNL 0. 3-1 mg/dl WBC 6. 3 WNL 3. 5-10 .
5 Glucose 103 HIGH 80-100mg/dl Lymphocytes 19. 8% LOW 20-40% Alk. Phos. 101 WNL 3-120 units/l Monocytes 8. 1% WNL 2-10% ALT ALT ALT AST 15/25 WNL 4-36 units/L 0-35 units/dl Eosinophils 3. 8% WNL 1-4% Amyl a s e Amyl a s e N/A 60-120 units/dl Basophils 2. 2% HIGH 0. 5- 1% Lip a se N/A 0-160 units/L MCV 91. 2 WNL 80-95 µm3 CPK N/A 30-170 units/L MCHC 35. 3 WNL 32-36 gm/dl Troponin N/A <0. 03 ng/mL MHC 32. 0 WNL 27-32 pg BNP N/A <100 pg/mL MPV N/A 7.
4-10. 4 fL LDH 100- 190 units/L Sed. Rate N/A 15 mm/hr Cholesterol 138 WNL <200 mg/dl D-Dimer N/A <250-600 ng/m L HDL LDL 39/77 WNL >45 mg/dl 60-180 mg/dl Bleeding Time N/A 1-9 minutes Triglycerides 112 WNL 35-160 mg/dl Digoxin level N/A 15-25 ng/mL Date Test/Finding Result Reason out of Norm 3/26/14 GLUCOSE 103mg/dl POSSIBLE STRESS TO THE BODY FROM THE INFECTION 3/25/14 ALBUMIN 3.
3L INSUFFIECIENT PROTEIN ABSORBTION POSSIBLE R/T DECREASED LIVER FUNCTION DUE TO ALCOHOLISM HX 3/25/14 LYMPHOCYTES 19. 8% INFECTION OF THE LEG AND POSSIBLE MALNUTRITION 3/25/14 BASOPHILS 2. 2% Unknown K+ Gluc 70-110 mg/dl INR PT M 42-52% F 37-47% HCT 9-10. 5mg/dl 1. 3-2. 1mEq/L 3-4. 5mg/dl Mg+ Ca++ Student Name: ____ Date: ____3/27/14__________ 5 Pathoph ys iolo gy Treatments Risk Factors Nursing diagnosis Cellulitis INFLAMMATION OF THE SUBCUTANEOUS TISSUES; POSSIBLY SECONDARY COMPLICATION OR PRIMARY INFECTION;
OFTEN FOLLOWING BREAK IN SKIN; THERE IS A DEEP INFLAMMATION IN THE SKIN CAUSING EDEMA, ERYTHEMA, TENDERNESS, AND PAIN. STAPHYLOCOCCUS AUREUS AND STREPTOCOCCI ARE THE USUAL CAUSATIVE AGENTS. RISK FACTORS INCLUDE TRAUMA, LEG ULCERS, VENOUS STASIS AND INSUFFICIENCY, OBESITY, HX OF CELLULITIS, PREVIOUS VASCULAR SURGERY, DM, CHRONIC RECURRENT FUNGAL INFECTION OF FEET/TOES, OBESITY, OSTEOMYLITIS, BURNS, IMPAIRED SKIN INTEGRITY, AND STAPHYLOCOCCUS AUREUS AND BETA-HEMOLYTIC STREPTOCOCCI IN THE TOE WEBS.
ANTIBIOTICS PAIN MEDICATION KEEP SKIN MOISTURIZED PROPER WOUND CARE MANAGEMENT ELEVATE LIMB MONITOR INFLAMMATION EDUCATE ON PROPER HYGIENE IMPAIRED TISSUE INTEGRITY PAIN INEFFECTIVE SELF-HEALTH MANAGEMENT Medica l Diag nosi s Student Name: ____ Date: ____3/27/14__________.
6 SYSTEM FINDING SYSTEM FINDING CARDIOVAS CULAR BP 132/77 GI ABDOMINAL CONTOUR/FIRMNESS UNABLE TO ASSESS PULSES (BILATERALLY WHEN APPLICABLE) RADIAL 2+ BOWEL SOUNDS X 4 QUADRANTS UNABLE TO ASSESS RHYTHMNORMALSINUS RHYTHM LAST BM AM APICAL RATE 76 BOWEL PROGRAM BEDPAN RADIAL 74 DENTITION PERMANENT TEETH CAPILLARY REFILL <2 SECONDS URINARY AMOUNT 300 ML HEART Sounds S1, S2,S3,S4, Rub S1 AND S2 HEARD, NO MURMURS CONTINENT OR INCONTINENT.
CONTINENT MURMUR NO MURMURS BLADDER PROGRAM URINAL RESPIRATOR Y RATE 18 SKIN INTEGRITY SKIN NOT INTACT, RED AROUND DRESSING SITE, TENDER, RHYTHM NORMAL HYDRATION/TURGOR VERY DRY, FLAKY, CRUSY, NO TENTING EFFORTNO INCREASED EFFORT LESIONS/SCARS/WO UNDS (LOCATION AND DESCRIPTIONS) SCALY, DRY SCARS AND LESIONS SHOWN ON ARMS, MANY ON EXTREMITIES PULSE OXIMETRY 96%EDEMA.
(LOCATION/AMOUNT ) 1+ EDEMA AT LOWER EXTREMITY RIGHT LEG. BREATH SOUNDS NO AUDIBLE RHONCHI M/S MOBILITY/STRENGTH UPPER STRENGTH 5 LOWER STRENGTH 2-3 LUL CLEAR ASSISTIVE DEVICES N/A LLLCLEARBUT DIMINISHED IMMOBILIZATION DEVICES (TRACTION/CAST/FIX ATORS).
N/A RUL CLEAR NEUROLO GIC TEMPERATURE 97. 3 RML CLEAR LOC ORAL RLLCLEARBUT DIMINSIHED SPEECH NON IMPAIRED, ABLE TO COMMUNICATE COUGH DRY COUGH, VISION NO ABNORMALITIES, WEARS CORRECTIVE LENSES Student Name: ____ Date: ____3/27/14__________ 7 SECRETIONS/S PUTUM AMOUNT/APP EARANCE NO SECRETIONS WERE EXPECTORATED HEARING NO DEFICITS PRESENT IN HEARING MUCOUS MEMBRANE COLOR.
PINK/MOIST SLEEP PATTERN ABLE TO SLEEP THROUGHOUT NIGHT O2 ADMINISTRATIO N DENIED GCS 15 PAIN *Can finish this bottom part of page during Clinical 1. List other disciplines involved in the Patient’s Care: Talked to patient about 2. Describe any need for assistance after discharge, Assistance is needed when ambulating leg, wound care plans with follow-up.
3. Describe and discuss patient teaching: I went over various points about how his overall health is related to his cellulitis, including his heart and good circulation. 4. List what you taught or reinforced to the patient/family. Name of pamphlet or handout used (ifapp li c a b le ) Location Duratio nCause/Description Pain SCALE CONTROL METHOD/MANAGE MENT EFFECTIVENE SS OF RELIEF LEFT LOWER LEG 1 HOURACHING PAIN2NPO STATUSNO RELIEF/PAIN DID NOT INCREASE Student Name: ____ Date: ____3/27/14__________ 8.
Discussed with patient about symptomsto watch for, good personal hygiene, skin care, andways to reduce anxiety. 5. Name one of the resources that you looked up (can be a policy or procedure, research article, etc. ) n/a Student Name: ____ Date: ____3/27/14__________ 9 Medication page Medicat ion: Trade and Generic names Pharmacother apeutic Classification & Drug Action Normal Dosag e Rang e Amt. Dr. ordered Route and Ti me Why is Patient receiving medication?
Life threatening and most common reactions to monitor/observe Nursingresponsibilities MUPIROCIN (BACTROBAN) ANTI-INFECTIVE/ INHIBITSBACTERIAL PROTEIN SYNTHESIS. HIGH LOW N/A N/A APPLY LIBERALLY DAILY TO AFFECTED SKIN TOPICAL OINTMENT TO AID IN THE TREATMENT OF BACTERIAL INFECTION CNS: NASAL ONLY: HEADACHE EENT: NASAL ONLY: COUGH, ITCHING, PHARYNGITIS, RHINITIS, UPPER RESPIRATORY TRACT CONGESTION GI: NAUSEA NASAL ONLY: ALTERED TASTE DERM: TOPICAL ONLY: BURNING, ITCHING, PAIN, STINGING INSTRUCTPATIENTON THE CORRECT APPLICATION OF MUPIROCIN.
ADVISE PATIENT TO APPLY MEDICATION EXACTLY AS DIRECTED FOR THE FULL COURSE OF THERAPY. IF A DOSE IS MISSED, APPLYAS SOON ASPOSSIBLE UNLESS ALMOSTTIME FOR NEXT DOSE. AVOID CONTACT WITH EYES. VANCOMYCIN ANTI-INFECTIVE/ BINDS TO BACTERIAL CELL WALL, RESULTING IN CELL DEATH.
HIGH 500MG IV LOW 20 MG/DAY 1. 0 MG IVP Q12H OUTER RIGHT FOREARM PATIENT IS RECEIVING THIS MEDICATION TO HELP TREAT HIS ULCER INFECTION AND CELLULITIS. EENT: OTOTOXICITY CV: HYPOTENSION GI: NAUSEA, VOMITING GU: NEPHROTOXICITY DERM: RASHES HEMAT:
EOSINOPHILIA, LEUKOPENIA LOCAL: PHLEBITIS MS: BACK AND NECK PAIN INSTRUCTPATIENTTO REPORT SIGNS OF HYPERSENSITIVITY, TINNITUS, VERTIGO, OR HEARING LOSS. ADVISE PATIENT TONOTIFY HEALTH CARE PROFESSIONAL IF NO IMPROVEMENT IS SEEN IN A FEW DAYS. PATIENTS WITH A HISTORY OF RHEUMATIC HEART DISEASE OR VALVE REPLACEMENT NEED TO BE TAUGHT IMPORTANCE OF USING ANTIMICROBIAL PROPHYLAXIS PRIOR TO INVASIVE DENTAL OR MEDICAL PROCEDURES. ZOSYNANTIBIOTICHIGH3. 375IVR PATIENTIS PRURITIS, CONSTIPATION, MONITOR CBC, TEMP, Student Name: ____
Date: ____3/27/14__________ 10 (PIPERACILLIN SODIUM AND TAZOBACTAM) 4. 5 G/100ML/ 30 MIN LOW 2. 25G/50 ML/30 MIN GIV OUTER FOREARMQ 6 RECEIVING THIS MEDICATION TO HELP TREAT HIS ULCER INFECTION AND CELLULITIS. HEADACHE/INSOMNIA.
MORE SERIOUS-STEVENS-JOHNS ON SYNDROME, C. DIFF, THROMBOCYTOPENIA,ANA PHYLAXIS IMPROVEMENT OF S/S, ELECTROLYTES,WATCH FOR SIGNS OF BLEEDING, INSTRUCT PT TO REPORT WATERY/BLOODY DIARRHEA HYDROCODONE (VICODIN) OPIOID AGONISTS NONOPIOID ANALGESIC COMBINATIONS/ BIND TO OPIATE RECEPTORS IN THE CNS. ALTER THE PERCEPTION OF AND RESPONSE TO PAINFUL STIMULI WHILE PRODUCING GENERALIZED CNS DEPRESSION HIGH 10 MG LOW 2.
5 MG NOT LISTED PO PATIENT IS RECEIVING THIS MEDICATION TO HELP WITH PAIN OF AFFECTED LEG. CNS: CONFUSION, DIZZINESS, SEDATION, EUPHORIA, HALLUCINATIONS, HEADACHE, UNUSUAL DREAMS EENT: BLURRED VISION, DIPLOPIA, MIOSIS RESP: RESPIRATORY DEPRESSION CV: HYPOTENSION, BRADYCARDIA GI: CONSTIPATION, DYSPEPSIA, NAUSEA, VOMITING GU: URINARY RETENTION DERM: SWEATING ADVISE PATIENT TOTAKE MEDICATION AS DIRECTED AND NOT TO TAKE MORE THAN THE RECOMMENDED AMOUNT.
SEVERE AND PERMANENT LIVER DAMAGE MAY RESULT FROM PROLONGED USE OR HIGH DOSES OF ACETAMINOPHEN. RENAL DAMAGE MAY OCCUR WITH PROLONGED USE OF ACETAMINOPHEN OR IBUPROFEN. DOSES OF NONOPIOID AGENTS SHOULD NOT EXCEED THE MAXIMUM RECOMMENDED DAILYDOSE. DO NOT STOP TAKING WITHOUT DISCUSSING WITHHEALTHCARE PROFESSIONAL; MY CAUSE WITHDRAWAL SYMPTOMS IF DISCONTINUED ABRUPTLY AFTER PROLONGED USE.
INSTRUCT PATIENT ON HOW AND WHEN TOASKFOR AND TAKE PAIN MEDICATION. ADVISE PATIENT THAT Student Name: ____ Date: ____3/27/14__________ 11 HYDROCODONE IS A DRUG WITH KNOWN ABUSE POTENTIAL. PROTECT IT FROM THEFT, AND NEVER GIVE TO ANYONE OTHER THAN THE INDIVIDUAL FOR WHOM IT WAS PRESCRIBED. MAY CAUSE DROWSINESS OR DIZZINESS.
ADVISE PATIENTTO CALL FOR ASSISTANCE WHEN AMBULATING OR SMOKING. CAUTION PATIENT TO AVOID DRIVING OR OTHERACTIVITIES REQUIRING ALERTNESS UNTIL RESPONSE TO THE MEDICATION IS KNOW BUPROPIAN (APLENZIN) ANTIDEPRESSANT/ DECREASES NEURONAL REUPTAKE OF DOPAMINE IN THE CNS. DIMINISHED NEURONAL UPTAKE OF SEROTONIN AND NOREPINEPHRINE (LESS THAN TRICYCLIC ANTIDEPRESSANTS).
HIGH 450 MG LOW 150 MG 150 MG PO BID TREATMENT OF MAJOR DEPRESSIVE DISORDER CNS: SEIZURES, SUICIDAL THOUGHTS/BEHAV IOR, AGITATION, HEADACHE, AGGRESSION, ANXIETY, DELUSIONS, DEPRESSION, HALLUCINATIONS, HOSTILITY, INSOMNIA, MANIA, PANIC, PARANOIA, PSYCHOSES GI:
DRY MOUTH, NAUSEA, VOMITING, CHANGE IN APPETITE, WEIGHTGAIN, WEIGHT LOSS DERM: PHOTOSENSITIVITY ENDO: HYPERGLYCEMIA, HYPOGLYCEMIA, SYNDROME OF INAPPROPRIATE ADH MAY IMPAIR JUDGMENT OR MOTOR AND COGNITIVE SKILLS. ADVISE PATIENT, FAMILY, AND CAREGIVERS TO LOOK FOR SUICIDALITY, ESPECIALLY DURING EARLY THERAPY OR DOSE CHANGES.
NOTIFY HEALTH CARE PROFESSIONAL IMMEDIATELY IF THOUGHTS ABOUT SUICIDE OR DYING, ATTEMPTSTO COMMIT SUICIDE, NEWOR WORSE DEPRESSION OR ANXIETY, AGITATION OR RESTLESSNESS, PANIC ATTACKS, INSOMNIA, NEW OR WORSE IRRITABILITY, AGGRESSIVENESS, ACTING ON DANGEROUS IMPULSES, MANIA, OR OTHER CHANGES IN MOOD OR BEHAVIOR OCCUR. NFORM PATIENT THAT FREQUENT MOUTH RINSES, GOOD ORAL HYGIENE, AND SUGARLESSGUM OR CANDY Student Name: ____
Date: ____3/27/14__________ 12 SECRETION NEURO: TREMOR MAY MINIMIZE DRY MOUTH. IF DRY MOUTH PERSISTS FOR MORE THAN2 WK, CONSULTHEALTH CARE PROFESSIONAL REGARDING USE OF SALIVA SUBSTITUTE.
# 1 Nursing Diagnosis ____IMPAIRED TISSUE INTEGRITY_____________________________________________________ R/T AEB Patient’s Goals (label them short term or long term) Short term-must be measurable for the duration of clinical Long- t erm- measurable after clinical) Nursing Actions (Interventions in order of priority) Rationale for Actions E val ua tion of Interventions Patient /significant/f a mil y educa tional needs R/T: DAMAGED/INFLAMED TISSUE SECONDARY TO CELLULITIS & INFECTED VENOUS STASIS ULCER AEB:
ERYTHEMA, POOLING, EDEMATOUS SHORT TERM: PATIENT WILL MAINTAIN TISSUE INTEGRITY BY SHOWING NO TISSUE BREAKDOWN, OR INCREASING SIGNS OF INFECTION. LONG TERM: PATIENT WILL BEGIN TO SHOW 1. MONITOR STATUS OF SURROUNDING SKIN OF THE DRESSING, NOTING APPEARANCE, ANY SKIN BREAKDOWN, ASSESSING FOR ANY ESCHAR OR DRAINAGE.
2. KEEP SKIN MOIST WITH BARRIER CREAM, 1. THIS KEEPS ME AWARE THROUGHOUT MY SHIFTOF ANY CHANGES FROM THE BASELINE ASSESSMENT 2. THIS WILL PROMOTE WOUND HEALING BY KEEPING SKIN FLEXIBLE, WHILE PREVENTING IRRITATION AND 1. WHILE THE INFECTED AREA WAS COVERED FOR MY SHIFT, I WAS ABLE TO SAFELY MONITOR THE SURROUNDING TISSUES EFFECTIVELY AND KEEP FROM FURTHER DAMAGE.
2. APPLIED BARRIER LOTION TWICE IN THE SHIFT TO PROMOTE SKIN INTEGRITY,AND 1. PATIENT NEEDS PROPER EDUCATION ON APPLYING DAILYLOTION TO THE BODY TO PREVENT DAMAGE TO THE SUPERFICIAL LAYER. 2. PATIENT EDUCATION OF ELEVATION OF LOWER LIMB AND RATIONALE 3. TALK WITH PATIENTABOUT RECURRENT SIGNS Student Name: ____
Date: ____3/27/14__________ 13 SURROUNDING TISSUE, WARM SKIN, AND TENDERNESS. SIGNS OF IMPROVEMENT, LIKE DECREASED SWELLING, DECREASED REDNESS, AND DECREASES TENDERNESS IN THE INFECTED AREA INCLUDING UNAFFECTED LEG. 3. POSITION LEG PROPERLY BY POSITIONING ON PILLOWS FURTHER SKIN BREAKDOWN (LEWIS, 462) 3. REDUCES PRESSURE AND AIDS WITH VENOUS RETURN (LEWIS). KEEP DRY SKIN FROM CRACKING.
3. KEPT LEG LIFTED ON 1-2 PILLOWS, AND TURNED PATIENT TO REDUCE PRESSURE. OF CELLULITIS AND INFORM DR IF TENDERNESS, PAIN, OR SWELLING DOES NOT GO AWAY.
2 Nursing Diagnosis ______Pain, chronic ___________________________________________________ R/T AEB Patient’s Goals (label them short term or long term) Short term-must be measurable for the duration of clinical Long-term- measurable after clinical Nursing Actions (Interventions in order of priority) Rationale for Actions Evaluation of Interventions Educational needs Student Name: ____ Date: ____3/27/14__________ 14 R/T: TENDERNESS, SWELLING, TAUGHT SKIN, INFECTED TISSUE. AEB:
FACIAL GRIMACING WHEN MOVING LEG, ANXIETY OR ANGER. SHORT TERM:. WHILE THE PATIENT WAS TO REMAIN NPO THROUGHOUT THE MORNING FOR DEBRIDEMENT, FOLLOWING POST-OP, HE SHOULD FOLLOW BACK TO ORAL REGIME INCLUDING PAIN MEDICATIONS. LONG TERM: PATIENT WILL LEARNWAYS TO REDUCE ANXIETY AND COPE WITH PAIN, SINCE THIS DISORDER DOES HAVE A CHANCE OF RECURRING AGAIN.
1. ADMINISTER MEDICATIONS AS PRESCRIBED TO AID WITH PAIN AND TISSUE HEALING. 2. HELP WITH ANXIETY BY DISTRACTING CLIENT AND KEEPING MIND AWAY FROM THE PAIN TEMPORARILY. 3. DISCUSS NON-INVASIVE THERAPEUTIC INTERVENTIONS.
1. PAIN MEDS WILL COMFORT PATIENT, EASING THE PAIN. ANTIBIOTICS WILL DECREASE BACTERIAL GROWTH THAT IS CAUSING TISSUE INFLAMMATION, AND SWELLING. 2. DISTRACTION USUALLY INCREASES PAIN TOLERANCE AND DECREASES PAIN INTENSITY (CARPENITO110)
3. MAYBE BE MORE HELPFUL SINCE PAIN IS CHRONIC 1. WAS ABLE TO EFFECTIVELY ADMINISTERZOSYN AND VANCOMYCIN TO PATIENT TO AID WITHBACTERIAL INFECTION. 2. DURING MY TIME WITH THE PATIENT, WE DISCUSSED SPORTS, RELIGION, AND SCHOOL, WHICH I COULD TELL AIDED WITH THE PAIN, EVEN IF IT WAS TEMPORARILY.
3. WAS ABLE TO TALK TO PATIENT ABOUT EXAMPLES LIKE PRAYING, SLEEP, AND MASSAGE. 1. education on long term effects of pain, and how anger, mood, and depression can ultimately affect daily living. # 3 Nursing Diagnosis ____Ineffective self-health management R/T Patient’s Goals (label them short term or long term) Short term-must be measurable for the duration of clinical Long- t erm- measurable after clinical Nursing Actions (Interventions in order of priority) Rationale for Actions Evaluation of Interventions Educational Needs Student Name: ____
Date: ____3/27/14__________ 15 R/T: Insufficient knowledge, prevention, treatment, and skin care AEB: Poor hygiene practice, poor wound care r/t recurrent infection. Short term: Patient will demonstrate or verbalize the importance of treatment regime. Long term: Patient will show a desire for treatment, and include it in his daily living, and will show overall improvement of leg healing.
1. Educate the patient on proper hygiene and how it can great affect to his overall health. 2. Told a past success story to encourage him to take control of health. 3. Emphasize the importance of taking control of wound, and discussing early symptoms of recurrent infections and what to look out for. 1. Patient in the am refused am care, which notified me to assess his awareness of hygiene and wound management.
2. Reduces anxiety by promoting confidence and positive self efficacy (Carpeni t o,587) 3. This promotes or implements symptom-focus ed self-care management (Carpenito, 586) 1. was able to effectively get my point across when the patient stated“so keeping my skin clean will help me keep the infection away”.
2. Told him about my wound healing story, and how I was able to overcome difficulties. 3. Discussed signs like fever, increased swelling, swollen lymph nodes, and pain to watch out for. Continue to enforce wound healing measures and practice good hygiene to prevent recurrent infections. Student Name: ____ Date: ____3/27/14__________ 16.