Week 5 Nursing Care Plan Student Name: Raenell Curry, WCU SN Patient Medical Diagnosis: Sickle cell anemia

& R foot wound Assessment Data Goals & Outcome (2 short term & 1 long term) 1. Patient will Subjective: EH, 16 yr old female admitted maintain from clinic 6/28/13 with a optimal skin stage 3 pressure ulcer on right integrity aeb medial ankle that started off absence of as a sore 3 months ago and rashes and skin progressed. Pt failed multiple lesions in 6 PO antibiotic treatments. months and will notify healthcare team Objective: Stage 3 R foot wound 1.2 cm of any new x 2 cm with fibrinous developments exudates (yellow and early so that purulent) over medial treatment can mealleolus. Wound dressing be clean, dry & intact, dressing implemented. change every 2-3 days per PT due 7/2/13. Right thumb PIV, regular diet Vanc trough 2. Patient will 7/1/13 @ 1310= 4.3 and on change 6/30/13= 4.1. NKDA, pt has a dressing h/o poor healing. WBC on correctly after admittance= 6630. Culture teaching per PT done on admittance: gram within 2 days. positive cocci in clusters & Nursing Interventions Rationale Outcome Evaluation Date: 7/2/13

1a. Assess for skin integrity and rash.

1a. Butterfly rash may present along with small lesions. 1b. This can prevent further skin breakdown.

1b. Assess the need for prophylactic pressurerelieving devices. 1c. Teach patient to avoid moisture on wound.

1. Patient has no other evident skin breakdown. Pt uses pillows as pressure relieving device.

1c. Moisture can increase risk of infection.

2a. Teach patient to clean, dry and moisturize intact skin. Clean with warm water and use unscented lotion and mild shampoo. 2b. Properly changing

2a. Scented lotions may contain alcohol which dries skin. Hot water may scold patient.

2b. Dressing changes can

2. Patient kept wound and IV clean and dry while bathing. PT came and taught helped patient change dressing.

rods, light growth, stenatophones, maltophilia & bacteroides uniform with normal flora. I=480 mL & O=1200 mL on 7/2. Pt menstruating. Pain 3/5 @ 0745 & 1050 and 2/5 @ 1230. Administered ordered prn pain med, Loratab elixir 7.5 mL PO q4h @ 1100. Nursing Diagnosis: Impaired skin integrity aeb right foot wound r/t slow healing process.

dressing can promote healing. 3. Patient will maintain adequate nutrition and hydration within one day. 3a. Encourage patient to increase oral intake. 3b. Assess for s/sx of dehydration.

keep the wound clean and dry. 3a. This promotes healthy skin and healing. 3b. Dehydration can further impair healing process. 3. I=480 mL & O=1200 mL, pt ate most of meal plates. Pt had no fluctuations in weight.