Question

Jenny walker 48-years-old who has a history of diabetes and circulatory problems, underwent abdominal surgery several days ago and is now in the critical care unit. When you enter, she is slouched down in bed. Assessment reveals that her abdominal dressing is moist, and only part of the tape securing the dressing is adhering to the skin. Her level of consciousness is decreased, and she responds only to moderate touch and pain. With repositioning, she moans. Further assessment reveals the beginning of a pressure ulcer on her heels. She is NPO and has a central venous catheter in place for administration of total parenteral nutrition (TPN). An indwelling catheter in place to accurately measure intake and output. She is currently afebrile but has been prescribed antibiotics prophylactically.

Patient has the following vital signs:

Blood pressure- 124/78

Pulse- 88

Respiration- 19

Temperature - 98.9 F

Blood sugar- 117 mg/dl

Present a concept map displaying the nursing process for Jenny.

1. State 3 nursing diagnoses in priority order

2. Include the supported data whether subjective if any, and objective for each nursing diagnosis.

3. Write one (1) important outcome for each nursing diagnosis.

4. Write two (2) nursing interventions in order of priority for each nursing diagnosis.

Answer 1

1.

a. Risk for infection related to person who had undergone surgical operations as evidenced by moist dressing in the surgical site.

b. Impaired skin integrity related to immobility as evidenced by bedsore.

C. Altered level of consciousness related to disease conditions.

2.a. risk for infection

Subjective

Patient denies malaise

Objective data

Presence of delayed healing at the surgical incision site

Moist dressing and opened wound.

b. Impaired skin integrity

Subjective

Patient may verbalize that i am having pain in the site(heels or where bedsore present )

Objective data

Facial grimace

Irritability

Bedsore in the heels

C. Altered level of consciousness

Subject

Patient may say that i don't know where i am.

Objective

Not responding to stimuli

Gcs score :9

3.riskfor infection

Outcome:the patient will remains free of signs and symptoms of infection

Impaired skin integrity

Outcome:the patient will achieve timely wound healing.

Altered level of consciousness

Outcome:patient will regain normal level of consciousness in someextend

4.risk for infection

nursing intervention

Check the vital signs of the patient

Use aseptic techniques before and after the procedure

Impaired skin integrity

Nursing intervention

Assess and document the color, depthand size of the wound and surrounding skin

Frequently change the position of patient and back care to be done

Altered level of consciousness

Assess the gcs score of the patient

Provide comfortable position to prevent aspiraton.