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Nursing Diagnosis # 1: Infection related to wound on the right forearm caused by cellulitis with MRSA found in the wound culture causing erythema, pustules and edema, elevated temperature of 101.5 F and increased WBC count of 16,000.
Goal/Outcome: The client will display decreased signs of infection as evidenced by reduced wound redness, swelling, pain and drainage within 8 hours.
Nursing Interventions
Rationale
Patient Responses to Interventions
Assess the wound site for further signs of infection such as increasing redness, swelling, pain and drainage.
1. Assessing the wound provides for a baseline to compare the advancement of the wound and the effectiveness of treatment.
(Taylor, 1060)
1. No increased signs of infections. The redness, swelling , pain and drainage of the rash on the right forearm has decreased.
Administer Trimethoprim/Sulfamethoxazole 160mg/800mg Q12 hours po X 7 days
Monitor for side effects
2. Administering Trimethoprim/Sulfamethoxazole as directed will treat and prevent further infection while simultaneously monitoring for possible hazardous side effects such as fevers.
(Taylor, 648)
2. 160mg/800mg Trimethoprim/Sulfamethoxazole administered every 12 hours for 7 days by mouth with no adverse reactions noted.
Follow strict aseptic technique when irrigating and changing a Normal saline wet to dry dressing every 12 hours on the right forearm.
3. Irrigating and changing the dressing of a wound following sterility promotes wound healing with removing microorganisms.
(Taylor, 1070)
3. No wound drainage present when dressing was changed at 12pm.
Adhere to standard contact precautions
4. Following contact precautions prevents the spread of MRSA to other patients as well as prevents possible contamination to the patient’s wound of other microorganisms.
(Taylor, 615)
4. Contact precautions were followed when entering the patient's room, and hand hygiene was performed.
Monitor vital signs every 4 hours.
5. Having the baseline of vitals and checking for changes every 4 hours shows physiological improvement or decline such as temperature rising with infection present.
(Taylor, 643)
5. 8 am: Temp 99F, Pulse 89/bpm, respirations 20/min, B/P 145/80
12 pm: Temp 98F, Pulse 85/bpm, respirations 18/min, B/P 130/78
Patient/Family Teaching:
Teach patient the importance of continuing taking medication for the full duration. Teach patient how to assess the wound for increase of infection. Teach patient proper hand hygiene and proper wound dressing changes.
Evaluation:
Patient showed improvement in signs and symptoms of the infection.The wound showed no evident increase in redness, swelling, pain and drainage. The WBC count was reduced to 13,000. There were no adverse reactions to the medication.
Goal Met
References:Taylor, C., Lynn, P., & Bartlett, J.L. (2019). Lippincott CoursePoint for Fundamentals of Nursing (9th Ed.). Philadelphia: Wolters Kluwer, ISBN:9781496362179
Nursing Diagnosis # 2: Impaired gas exchange related to ventilation perfusion imbalance secondary to COPD shown by labored, rapid breathing at 26 respirations per minute, SpO2 is 89% with room air, patient verbalized, “unable to walk more than several yards without getting tired or short of breath”
Goal/Outcome: Patient will perform regular gas exchange with SpO2 returning to >94%, as well as unlabored respirations within 12-20 per minute within 12 hours.
Nursing Interventions
Rationale
Patient Responses to Interventions
1. Assess vital signs emphasizing respirations frequently
1. Frequent respiratory assessment is to determine whether the patient's breathing is normalizing. Vitals are to monitor other complications.
1. 7am: BP: 140/80 Temp: 99.9F Pulse: 100 bpm RR: 26/min
10am: BP: 136/78 Temp: 98.9F Pulse: 94 bpm RR: 23/min
1pm: BP 130/75 Temp: 98.7F Pulse: 88 bpm RR: 19/min
2. Administer Spiriva daily 1 puff inhaler as prescribed
2. Bronchodilator inhalers help open airways which may narrow from COPD (Taylor, 1506)
2. Spiriva was administered timely with correct patient demonstration.
3. Auscultate anterior and posterior lung sounds using stethoscope
3. Auscultation of all lung fields can pinpoint abnormalities that may amplify increased respirations in a patient (Taylor, 958)
3. Lung sounds clear over all fields with no adventitious breath sounds
4. Administer oxygen via nasal cannula at 2L/min checking for skin breakdown or abnormalities
4. Oxygen therapy through nasal cannula improves breathing, and SpO2 levels (Taylor, 1508)
4. There is no skin breakdown surrounding nasal cannula
5. Encourage diaphragmatic breathing
5. Diaphragmatic breathing reduces respiratory rate, expelling as much air as possible during respiration (Taylor, 1504)
5. Patient performed breathing adequately using abdominal muscles upon inspiration, and pursing lips during expiration. Respirations per minute reduced while performing exercises
Patient/Family Teaching:
Educate patient on proper use of daily inhaler, as well as at home spirometer use and diaphragmatic breathing. Patient should cluster activites and schedule adequate rest periods
Evaluation:
Patient’s respirations have normalized, ranging to about 18 respirations per minute regular and unlabored. Patient uses his medication correctly and effectively as well as stays hydrated to help mobilize secretions. Goal has been met.
References: Taylor, C., Lynn, P., & Bartlett, J.L. (2019). Lippincott CoursePoint for Fundamentals of Nursing (9th Ed.). Philadelphia: Wolters Kluwer, ISBN:9781496362179
Nursing Diagnosis # 3: Risk for inadequate nutrition intake as evidence by loss of appetite, fatigue and 15 pound weight loss over 6 months due to the death of sister.
Goal/Outcome:
Patient will recognize the importance of having a good diet that is nutrient filled and show no signs of nutrient deficits or weight loss
Nursing Interventions
Rationale
Patient Responses to Interventions
1. Encourage him to verbalize his feelings, thinking, worries
1.Have the patient open up about why he is having loss of appetite
1.Patient feels lonely knowing his sibling is no longer there
2. Order a set of labs, monitor the patient’s input and output
2.Monitoring the weight can help us see if the calories are being increased or decreased to meet the patient’s body requirements (Taylor, 1297)
2.Patient was cooperative and gave blood sample to be checked. Initial weight was 130 in 4 days increased to 133.
3. Go over the patient’s history of what he eats. Gain information of what he prefers to eat and what he dislikes.
3. Patient’s will be more likely to follow a dietary regimen that is tailored to their preferences, culture, and lifestyle. (Taylor, 1301)
3.Patient gave a list of the foods he likes to eat and denied any allergies to any other foods.
4. Instead of having three big meals a day, give small portion meals throughout the day in a non invasive environment.
4. This will stimulate a patient’s appetite. (Taylor, 1301)
4. Patient ate majority of his meals throughout the day, verbalizing the small portions are easier to fully eat.
5. Do not hurry the client when interacting, instead be patient and show a sense of empathy.
5. Being patient and empathetic makes the patient feel safe and cared about.
5.Feels comfortable and safe, starts to realize he has support.
Patient/Family Teaching:
Teach the patient to monitor his weight when going back home. Additionally, patient should be taught the amount of calories he needs to intake daily with different meal plans to make it more appealing to eat.
Evaluation: The patient began showing signs of weight gain and no malnutrition after eating small meals throughout the day. He also verbalizes the importance of upkeeping with calories and having proper nutrition to be healthy.
References:
Taylor, C., Lynn, P., & Bartlett, J.L. (2019). Lippincott CoursePoint for Fundamentals of Nursing (9th Ed.). Philadelphia: Wolters Kluwer, ISBN:9781496362179
Nursing Diagnosis # 4: Hypertension related to respiratory issues as evidenced by PMH of COPD, blood pressure of 150/80, and taking 5mg daily PO of prescribed Enalapril.
Goal/Outcome: The patient’s blood pressure will lower by the end of the day, the patient will comprehend education of the therapeutic regimen, lifestyle modifications, and prevention of complications by the time of discharge.
Nursing Interventions
Rationale
Patient Responses to Interventions
1. Provide calm, restful surroundings, minimize environmental activity and noise. Limit the number of visitors and length of stay.
1. People with acute or chronic conditions may compromise circulation and place excessive demands on the heart. Helps lessen sympathetic stimulation; promotes relaxation.
1. The patient is relaxed and is not agitated (no extra stress is being put on the heart). Tolerated this intervention.
2. Check laboratory data (cardiac markers, complete blood cell count, electrolytes, ABGs, blood urea nitrogen and creatinine, cardiac enzymes, and cultures, such as blood, wound or secretions).
2. To identify contributing factors.
2. Patient was compliant in giving necessary components for these lab tests. Understands the importance of these tests and what they mean for the patient’s health in relation to their hypertension.
3. Monitor and record BP. Measure both arms and thighs three times, 3–5 min apart while the patient is at rest, then sitting, then standing for initial evaluation. Use correct cuff size and accurate technique.
3. Comparison of pressures provides a more complete picture of vascular involvement or scope of problem. Severe hypertension is classified in the adult as a diastolic pressure elevation to 110 mmHg; progressive diastolic readings above 120 mmHg are considered first accelerated, then malignant (very severe). Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated.
3. Patient tolerated this procedure, the patient was compliant with having BP taken.
4. Note presence, quality of central and peripheral pulses.
4. Bounding carotid, jugular, radial, and femoral pulses may be observed and palpated. Pulses in the legs and feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion.
4. The patient tolerated intervention and allowed pulses to be inspected, auscultated, and palpated. The patient understands the importance of having these nursing interventions done.
5. Auscultate heart tones and breath sounds.
5. S4 heart sound is common in severely hypertensive patients because of the presence of atrial hypertrophy (increased atrial volume and pressure). Development of S3 indicates ventricular hypertrophy and impaired functioning. Presence of crackles, wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure.
5. The patient tolerated having heart tones and breath sounds auscultated. The patient understands the importance of having the auscultations done.
Patient/Family Teaching: Educate about the role of stress in blood pressure management and assist with taking steps to control stress, signs and symptoms of high blood pressure, including headache, blurred vision, shortness of breath, dizziness, and chest pain, and about dietary changes to control blood pressure.
Evaluation: Patient had participated in activities to reduce BP/cardiac workload. The patient demonstrates stable cardiac rhythm and rate within the normal range. The patient participated in activities that will prevent stress (stress management, balanced activities and rest plan).
References:
Arbour, R. (2004). Intracranial hypertension monitoring and nursing assessment. Critical Care Nurse, 24(5), 19-32.
Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences.
Hamilton, G. A. (2003). Measuring adherence in a hypertension clinical trial. European Journal of Cardiovascular Nursing, 2(3), 219-228.
Taylor, C., Lynn, P., & Bartlett, J.L. (2019). Lippincott CoursePoint for Fundamentals of Nursing (9th Ed.). Philadelphia: Wolters Kluwer, ISBN:9781496362179
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