Topic 1: Use of the Nursing Process to Care for a Complex Patient Ms. Janet Smit
ID: 239319 • Letter: T
Question
Topic 1: Use of the Nursing Process to Care for a Complex Patient
Ms. Janet Smith is a 45-year-old African-American female who was admitted to a medical/surgical unit with a diagnosis of infection secondary to removal of ovarian cysts 1 week ago. Past medical history includes hypertension and diabetes mellitus Type 2. She also admits to a non-healing wound on her right toe, approximately 2cm x 2cm, red, swollen, with purulent drainage present on dressing. Home medications include enalapril (Vasotec) 5 mg PO BID, multivitamin one tablet daily, and insulin glargine (Lantus) 24 units subcutaneously QPM. Admission assessment data includes abdominal incision site warm to touch, erythematous, with small amount of purulent drainage on dressing. Patient rates pain of abdominal wound as 5 out of 10 on a 0-10 scale. She states the pain from her toe is an 8 out of 10 on a 0-10 scale. Admitting vital signs are: Temperature 99.7 F, oral, pulse 89, respirations 20, blood pressure 178/95, SpO2 97%, room air.
Admitting orders are as follows:
Admit to medical unit
Full Code
Allergies: sulfa, eggs
Activity, up with assist
Contact precautions
Enalapril (Vasotec) 5 mg PO BID
Multivitamin 1 tablet PO daily
Lantus insulin 24 units subcutaneous QPM
Fingerstick blood glucose AC & HS
Humalog insulin per sliding scale protocol
0.9% normal saline at 125 mL/ hr
Culture toe ulcer and abdominal wound STAT
Cefazolin (Kefzol) 1 gram in 100 mL IVPB Q8H
Acetaminophen 1000 mg PO Q6H prn pain
Wound consult
Blood cultures x 2 now
Enoxaparin 80 mg subcutaneously BID
CBC with differential, CMP, BNP, Hgb A1C now
CBC with differential, BMP in AM
1. What are the top three highest priority nursing diagnoses for this patient?
2. For the diagnoses you identified, create a list describing subjective and objective assessment data associated with the diagnosis and a plan of care for each nursing diagnosis.
3. Describe the methods that will be used to evaluate care given. Include a timeline, methods of gathering data, and benchmarks indicating success.
Explanation / Answer
1. Acute pain related to the open wound as evidenced by pain scale denotes 8 out of 10
2. Risk for infection related to non healing wound.
3. Lack of knowledge related to infection control measures as evidenced by wet dressing and raised temperature.
Subjective data: pain in the wound site.
Objective data: pain scale 8 out of 10, signs of infection present like purulent discharge, raise of temperature.
Goals: short term goal- after 8 hours of nursing intervention relief of pain and less risk for infection.
Long term goals- after 3 days of care patient able to do own wound care and knows more about wound infection and manifestation for wound healing.
Nursing intervention:
Perform daily wound care
Comfort measures to releive Pain like positioning
Note reduction in risk factors of occurrence localized signs of infection like swelling, redness
Administer medications for infection, pain as prescribed
Note intake and output chart to maintain fluid intake
Educate client and their family member about wound care and measures of wound healing like good hygiene, clean environment.
Encourage participation of family in wound care
Provide privacy for prayers
Provide magazines and newspapers as diversion therapy to pain
Evaluation: after 8 hours of care patient releive from pain, less risk to infection as the wound is cleaned and dressed and reduction in temperature. patient is more knowledgeable on infection control measures and intervention.