EDISON COLLEGE NURSING PROGRAMS NURSING CARE PLAN ASSESSMENT DATA (Appropriate data to support nursing diagnosis, include

subjective and objective data) NURSING DIAGNOSIS (Must include scientific rationale for the diagnosis, include references*) PLANNING Goals (include realistic short and long term client-centered goals) Short Term/Long Term Interventions Short Term: 1. At the end of the shift, patient will remain free of signs / symptoms of infection such as WBC count of 4,5003 10,000/mm , temp of < 100 F, and absence of purulent drainage wounds. Long Term: 1. At time of discharge, patient will be free of signs / symptoms of infection such as WBC count of 3 4,500-10,000/mm temp of < 100 F, and absence of purulent drainage wounds. NURSING IMPLEMENTATION (What actually was done, must include scientific rationale with references and delegation of tasks*) 1. Nurse monitored for signs and symptoms of infection, such as elevated systemic temperature, reddening of the area surrounding the wound, increased temperature of skin surrounding the wound, purulent wound drainage, and elevated WBC count multiple times throughout shift. Common assessment findings of an infected wound include purulent discharge, redness, warmth, fever, & elevated WBC. (Lemone 2011 pp.78, 288, 294-295) 2. Nurse administered antibiotics as per physicians orders. Antibiotics are medications used to treat bacterial infections and some have activity against a wide variety of bacteria. Prophylactic antibiotic treatment is effective in the prevention of postoperative complications. (Lemone 2011 p. 297) 3. Nurse provided regular EVALUATION (Actual outcome of care and appropriate follow-up actions) Goals Implementations Short Term goals evaluation: 1. At the end of shift, patient was free of signs / symptoms of infection. Temp - 98.7, 98.1. WBC was not ordered to be checked again during nurses shift. Wound characteristics were: RLL was only able to see drainage in wound vac, it remained serosanguinous. Toes (distal to injury) remained pink and not overly warm. Cranial incision did not produce any new drainage and was either excessively red or warm. Goal met. Long Term goal evaluation: 1. If client and nursing staff continue with these interventions, in all likelihood, the patient should remain free of signs / symptoms of infection. Goal on its way to being met. Evaluation of interventions: 1. Patient was monitored throughout shift for s/s of infection and none were present. Although no infection is present, continue intervention for

Subjective: Patient denies feeling febrile Patient denies malaise Patient denies history of MRSA Objective: 12cm craniotomy surgical incision on rear left of cranium, well approximated wound edges with dried serosanguinous drainage, healing by primary intention, closure with staples, granulation tissue present, skin around wound warm (normal warm) to touch Patient has a Foley urinary catheter Open fracture of right lower leg, heavily bandaged (doctors order to not remove), toenail cap refill of effected leg <3 seconds, skin on toes warm (normal warm) to the touch. Wound vac treatment on right lower leg, chamber containing serosanguinous drainage WBC: 7.1 Temp: 98.5F

Risk for infection R/T: surgical incision wound and open fracture of right lower leg Scientific Rationale: An open fracture carries significant risk for wound contamination and subsequent infection. The patient who undergoes surgery will have a postoperative wound. Any break in skin integrity must be monitored for infection. (Lemone 2011 p.1326) Pathophysiology: Infection occurs when an organism is able to colonize and multiply within a host. An infection causing microorganism must have virulence, be transmitted from its reservoir, and gain entry into the susceptible host. When the immune system is alerted that an invader has entered the body, cytokines send a message to phagocytes to attack the infection. Lymphocytes and other white blood cells also begin to attack the microorganism. The result of

Planned Nursing Interventions: 1. Throughout shift, nurse will continue to monitor for signs and symptoms of infection, such as elevated systemic temperature, reddening of the area surrounding the wound, increased temperature of skin surrounding the wound, purulent wound drainage, and elevated WBC count. 2. Nurse will administer

this activity often results in a fever and causes the blood vessels to enlarge in order to increase the amount of blood containing phagocytes and lymphocytes to the site of infection. (Lemone 2011 pp. 270-273, 292)

antibiotic drugs, as per physicians orders 3. Nurse will provide urinary catheter care & cleansing at least once per shift. 4. Nurse will observe proper hand hygiene and aseptic technique when caring for wounds. 5. Educate client on the importance of consuming adequate amounts of protein, calories, and fluids to promote wound healing.

catheter care with soap and water once during shift. *Delegated to female student nurse. Catheter care prevents access and limits bacterial ascent into, and growth in, urinary tract. (Doenges / Moorhouse / Murr 2010, p.353) 4. Nurse observed hospital policies and procedures in regard to hand hygiene and aseptic technique when caring for patients wounds. Hand hygiene remains the single most important factor in preventing the spread of infection. Standard precautions are essential in protecting the patient and the nurse from infection by preventing crosscontamination and exposure to infectious organisms. (Lemone 2011 pp.250, 302) 5. Nurse spoke to patient regarding the important role that protein, calories, and fluids play in the process of wound healing. Calories and proteins are needed to meet metabolic needs and promote wound healing. Fluids prevent dehydration and promote blood perfusion. (Doenges / Moorhouse / Murr 2010, p.679)

early detection. Goal met. 2. Patient was administered antibiotics as per physicians orders. No s/s of infection present. Goal met. Continue this intervention. 3. Patient was provided urinary catheter care once during shift. It was delegated to female nursing students. No s/s of infection present. Urinary catheter care is important in preventing contamination of the urinary tract, so continue this intervention. Goal met. 4. Adherence to hospital policy and procedure regarding hand washing and aseptic technique when providing wound care and/or observation was heeded. No s/s of infection present. Goal met. Continue this preventative intervention. 5. Nurse educated patient regarding the importance of nutrition, especially protein, calories, and adequate fluid intake in the process of healing. Patient demonstrated understanding of the concepts by restating. Goal met. Discontinue intervention.