Carlee Boyd

Concept Map

Ste. Marie

Problem No. 4 : Risk for infection r/t recent surgical interventions, altered skin integrity.

Goals: LT: Patient will remain free from symptoms of incisional infection after D/C ST: Patient will demonstrate appropriate hygienic measures such as handwashing, oral care, and perineal care by end of shift.

Nursing Interventions: 1.(C) Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. 2.(I)Assess skin for color, moisture, texture, and turgor . 3.(I) Encourage fluid intake. 4.(I) Use appropriate hand hygiene 5.(I) Teach the client risk factors contributing to surgical wound infection(e.g., smoking and higher body mass index)

Evaluations: 1.) Assessed wound for REEDA, and it did not seem to have any complications. (performed) 2.) Assessed skin, was a pink color, very moist and smooth, turgor was good. (performed) 3.) Asked client how much fluids she had been drinking, and told her that her wounds would heal better if she increased her intake, and help prevent infection. (performed) 4.) Each time I entered the room I used appropriate hand hygiene, sanitizer, or I put on gloves when assessing the wounds prone to infection. (performed) 5.) Told client factors that could potentially help cause infection, and client said she was not smoking and planned on eating better. (performed) *No modifications needed, cont with plan of care.

***NO OTHER RELATED DIAGNOSTIC STUDIES, MEDICATIONS, OR TEAM/REFERRALS

Carlee Boyd

Concept Map

Ste. Marie

Problem No. 3: Acute pain r/t ineffective anesthetic pain management, incisional pain Goals ST: Client will notify member of the health care team promptly for pain level greater than the comfort function goal, or occurrence of adverse effects, by end of shift. LT: Client will be able to perform activities of recovery or ADLs, such as getting around without pain and getting out of bed easily by D/C. Nursing Interventions: 1. (I) Assess pain level in client using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale every time vitals are performed. 2. (I) Determine the clients current medication use. Obtain an accurate and complete list of medications the client is taking or has taken. 3. (C) Administer opioids orally as ordered. 4. (I)Assess the client for pain presence after medication is administer, allowing appropriate time for it to have started working. 5. (I) Demonstrate the use of appropriate nonpharmacological approaches in addition to pharmacological approaches for helping to control pain, such as application of heat and/or cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music listening, and television watching. Evaluations: 1.) Before giving client medications, I asked her to give me her pain on a scale of 0-10, it was a 7, and where her pain was located, in her tailbone. (Peformed) 2.) Checked the clients chart and assessed what medications she had been prescribed and which ones she was taking. (Performed) 3.) Gave client Percocet as ordered/needed. (Performed) 4.) As I took vitals, I asked pt. if she was in any pain, on a scale from 0-10 she was a 7, when I went back to interview pt., she said she was down to a 3. (Performed) 5.) Taught client breathing techniques for when she was in pain, also showed her how to splint her incision when ambulating/moving and in pain. (Performed) No Modifications needed, continue with plan of care.

Carlee Boyd

Concept Map

Ste. Marie

Risk for infection r/t recent surgical interventions, altered skin integrity. SD: Client stated that she seemed to think her incision was red and swollen. OD: Incision was swollen and some what red, she did not seem to have exact instructions as to how it was suppose to be healing and what it should look like.

Acute pain r/t ineffective a management, incisional pa

SD: Client states that her p Says that she does not get without medications.

OD: Client is holding her in She also is not eating much moving.

Medical Dx : Cesarean section d/t arrest in dilation

Risk for constipation r/t recent anesthesia, medication administration, pain, or decreased mobility. SD: Client has not had a BM in over three days. States she does not have much of an appetite OD: Client is on Percocet. Is not eating any fiber and her fluid intake is not efficient enough.

Risk for bleeding r/t uterine a bleeding

SD: Client stated she had som really checked it since.

OD: Client had open abdomin was not educated on the care