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.

Answer 1

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.