Вы находитесь на странице: 1из 6

#629

Cellulitis

Student Name _____Naia Kassebeer_________

Date ____3/15/16__________

N256 Mini Care Plan

Nursing
Diagnoses
(NANDA)

Expected
(Complete before assessment)

Found
(Complete after assessment)

1. Acute pain related to irritation of the


skin, impaired skin integrity, ischemic
tissue.

1. Pain to leg 7/10 upon ambulation. Patient


reports that that pain resolves after the first
initial steps.

2. Impaired Skin Integrity related to the


presence of likely strept in the extremities
and changes in skin turgor AEB edema
and erythema

2. Small scab to right shin noted. Erythema


and edema present in lower right extremity and
surrounding wound.
3. Patient is afebrile. WBCs decreased to 11.2

3. Imbalanced body temp r/t


immunological response to infection
Focus of
physical
assessment

1) Assess pain
(quality/characteristics/location)

1.Pain to right shin is described as throbbing


and rated 7/10 upon movement or touch.

2) Assess wound on lower R shin for


signs and symptoms of infection. Assess
for erythmea and swelling around the site.
Assess for perfusion to the right lower
extremities. Assess for SIRS T> 38C
HR>90 RR>20 PaCo2 <32 WBC>12000

2. Small scab to right shin noted. Erythema


and edema present in lower right extremity and
surrounding wound. Cap refill less than 2
seconds to effected extremity No symptoms of
SIRS noted
3. Afebrile. WBCs 11.2.

3) Monitor for fever. Take temp Q 4hrs.


Monitor WBCs.
Need more
information
from
patient/family
/
Doctor about:

Top three
priorities
(goals) for
patient care

Who will be helping you at home?


What their learning style is
Does the patient understand the
importance of medication compliance and
aware of the side effects of the
medications?
Physical therapy?

Patient has older children and husband that can


assist patient with any limitations
Patient is able to verbalize medication
instructions and the importance of compliance
as well as side effects.
Physical therapy evaluated patient and found
that her ambulation was adequate without the
need for any assistive devices.

1. Patient will have an acceptable level of


pain
2. Client will show improvement of s/sx
of infection by end of shit

1. Patient complained of constant headache


rated 10/10 that improved to 3/10 after prn
med admin.
2. Patient was afebrile throughout the shift

3. Maintain body temperature within


normal range.
Nursing
Interventions

1. Assess the intensity, location, and


factors that aggravate or relieve pain.
-Record the location, the length of the
intensity scale (1-10) spread pain (To help
evaluate the place of obstruction and
cause pain)
-Give analgesics according to the
treatment program.
-Provide comfortable action, bleak back
rub, the rest. (Improve relaxation, reduce
muscle tension)
-Assist or encourage the use of focused
relaxation breathing.
-Give adequate rest and activity levels
2. Nurse will monitor meal consumption
and encourage>75% of food
consumption.
Monitor redness, swelling, and warmth
and compare to boundaries marked by
previous shifts
Administer ABX as ordered. Elevate
extremities

3. Erythema and edema improving AEB


wrinkling to the skin and improving mobility
and pain.
1) Pain to leg 7/10 upon ambulation.
Patient reports that that pain resolves
after the first initial steps. PRN
Motrin and Ibuprofen given with
positive effects. pain decreased to 3/10
and patient was comfortably sleeping
in bed upon reassessment. Patients
right leg remained elevated while
resting in bed.
2) Encouraged patient to eat meals.
Often verbalized that she was not
hungry but ensured that she was
consuming foods with her
medications. Administered IV
antibiotics as ordered. Right extremity
elevated while resting in bed.
3) Patient remained afebrile this shift and
remained comfortable. Patient refused
the need for any cooling measures.

3. Report Temp above 101F. Administer


PRN antipyretics Q4hrs for Temp above
100.4 and evaluate effectiveness, provide
fan, remove excess bedding as needed and
administer cool compress to neck, armpit
and groin area.
Teaching
needed/provi
ded

Teach about the importance of medication


compliance. If signs and symptoms
worsen to seek medical advice. Teach
about nutrition importance in wound
healing

Patient was able to verbalize the importance of


medication compliance and side effects of
medications as well as the need for proper
nutrition and wound healing.

Discharge
planning

Prevention- Take good care of your skin


(moisturize). Smoking delays wound
healing, get 7-9 hours sleep a night, eat a
healthy diet
When to seek attention from medical
provider
Area of skin is more red, tight or painful.
Skin area is very warm to touch.
Blood, pus, or other fluid coming from
any skin opening in the infected area.
Fever higher than 101.5 F (38.6 C).

Discharge instructions provided. Admission


checklist Compared and checks out.
Medication instructions provided. Patients
influenza and pneumovax vaccinations are up
to date. Patient educated on worsening
symptoms and when to contact MD. Patient
given written test to demonstrate knowledge of
medications. Test Xeroxed and filed. Patient
is aware of follow up appointment scheduled
for 3/23/16 and explained how to cancel the
appointment if unable to make it. Patient was

Chills or muscle aches.


Swelling in the area around or below the
infection
Pain that is not controlled with your
medicine

picked up by her husband and left the unit at


approximately 12:00 pm

#633

Pyelonephritis
Student Name _____Naia Kassebeer_________

Date ______3/15/16________

N256 Mini Care Plan

Nursing
Diagnoses
(NANDA)

Expected
(complete before assessment)

Found
(complete after assessment)

1. Acute pain (Flank and abdominal) r/t


inflammation and infection of the kidneys

1.Patient complains of constant sharp Right


sided flank pain that radiates to lower back and
Left groin pain 8/10

2. Imbalanced body temp r/t


immunological response to infection

Focus of physical
assessment

3. Impaired Urinary Elimination (dysuria,


urge, frequency, and / or nocturia) related
to infections of the kidney.

3. No complaints of dysuria, nocturia or


polyuria. Urine is light yellow.

1)Assess for back/ flank/ groin pain.


Quality, characteristics and duration of
pain. Alleviating/aggravating factors.
Assess for nausea/vomiting, skin turgor.

1.Patient complains of constant sharp Right


sided flank pain that radiates to lower back and
Left groin pain 8/10. Patients complains of
worsening pain upon movement and during
deep breathing and coughing. Alleviating
factors include repositioning and deep
breathing excersises.

2)Monitor for fever. Take temp Q 4hrs.


Monitor WBCs.

Need more
information
from
patient/family/
doctor about:

2. Patient is afebrile.

3) Assess for dysuria, frequency and


urgency upon urination. Inspect urine
specimen for color and odor.

2. Patient is afebrile. WBCs 8.5. BUN 18,


Creatinine 3.1 , GFR 20. Urinalysis reveled
Leukocytes, moderate blood and glucose
levels.

Family history.
Medical history, onset of disease.
Caregivers
Plan for stage 4 CKD

Father had a kidney transplant when he was


21.
Patient verbalized that she was born with
altered kidney function. She stated that she
has only been symptomatic a couple times
before due to UTIs. She stated her last
hospitilization was 10 plus years prior.
Patient stated her sister is a willing donor. She
plans to undergo a kidney transplant after she

fufills the dialysis requirment.


Top three
priorities (goals)
for patient care

1. Pain is controlled and at an acceptable


level

1. Maintain/improve respitory function


2. Pain is controlled and at an acceptable level.

2. Maintain body temperature within


normal range.
Patient will Verbalize understanding of
individual risk factors and appropriate
interventions.
Demonstrate behaviors for monitoring
and maintaining appropriate body
temperature.

3. Impaired urinary elimination

3. Impaired urinary elimination


Nursing
Interventions

1. Assess the intensity, location, and


factors that aggravate or relieve pain.
-Record the location, the length of the
intensity scale (1-10) spread pain (To help
evaluate the place of obstruction and
cause pain)
-Give analgesics according to the
treatment program.
-Provide comfortable action, bleak back
rub, the rest. (Improve relaxation, reduce
muscle tension)
-Assist or encourage the use of focused
relaxation breathing.
-Give adequate rest and activity levels
that can be tolerant.
(for muscle relaxation)
2. Report Temp above 101F. Administer
PRN antipyretics Q4hrs for Temp above
100.4 and evaluate efectivness
-provide fan remove excess bedding as
needed admnister cool compress to neck,
armpit and groin area.
3. -Measure and record the voiding of
urine each time. To investigate the change
of color, and to determine the input /
output.
-Advise to urinate every 2-3 hours.
-Palpation of the bladder every 4 hours.
(bladder distention)
-Help clients get a comfortable position to
urinate.
-Encourage increased fluid intake.

1. Gave PRN oxycodon and Tylenol that


decreased pain from an 8/10 to a 5/10. Patient
verbalized a decrease in pain after assisting her
reposition onto her left side. Promoted rest by
working with primary nurse and CNA to block
care.
2. Monitored v/s q 4 hours and as needed for
BP med administration and spo2 levels when
complaining about sypnes. Patient was
afebrile
3. Continued to monitor urinary elimination.
UOP was adequate light yellow. No foul odor,
cloudiness or cloudiness observed. Encouraged
frequent urination and moderate fluid intake
(renal diet)
4. Monitored respirations. RR 18, unlabored
and regular rhythm. Breath sounds were
diminished to lower lobes. Chest X ray
showed pleural effusion to base of right lung.
SPO2 was 97%. Encouraged use of IS.
Patient was only able to do 2 breaths per hour
(500ml). Performed a desat. Study. Patient
was able to ambulate 200 feet with no decrease
in SPO2.

(Flush bacteria)
Observations of changes in mental status:,
behavior or level of consciousness.
(Accumulated residual uremic and
electrolyte imbalance can be toxic to the
central nervous system).
Teaching
needed/provided

Discharge
planning

-Drug regimen (purpose, timing,


frequency, duration, and possible side
effects)-The role of nutrition and adequate
fluid intake-The manifestations of disease
recurrence. -The use of previously
successful coping mechanisms
Refer to nutritional counseling (A renal
failure diet controls the amount of protein
and phosphorus in your diet. You may
also have to limit calcium, sodium, and
potassium. A renal failure diet can help
decrease the amount of waste made by
your body, which can help your kidneys
work better)

Educated on the importance of medication


compliance and side effects. Provided
education on the importance of anticipating
pain and requestin pain medecine prior to the
pain getting out of control. Patient verbalized
understanding of renal diet and stated that she
had been following it rigidly.
Patient was unable to be discharged because of
inadequate pain control and the possibility of
pneumonia.
Patient needs to meet with a nutritionist for
renal diet education, A dialysis nurse to explain
the procedure and schedule the treatments
before she is a candidate for transplant.