Nursing Dx: Risk for infection related to inadequate primary defenses:

broken skin and history of infected grafts.

Expected outcome: Patient remains free of infection, as evidenced by
normal vital signs and absence of purulent drainage from wounds and
incisions post-op.
Nursing Interventions
Rationales
1. Monitor for signs of infection
Classic signs of any infection are
(redness, swelling, increased
localized redness, heat, swelling,
pain, purulent drainage,
and pain. Any suspicious drainage
increased temperature, color of
should be cultured. Yellow or yellowrespiratory secretions,
green sputum is indicative of
appearance of urine.)
respiratory infection. Cloudy, foulsmelling urine with visible sediment
is indicative of urinary tract or
bladder infection (Gulanick & Myers,
2014, p. 108).
2. Encourage intake of protein and
Optimal nutritional status supports
calorie rich foods. Encourage
immune system responsiveness.
fluid intake of 2000-3000ml of
Fluids promote diluted urine and
water per day.
frequent emptying of bladder,
reducing stasis of urine and
reducing risk for bladder infection or
UTI (Gulanick & Myers, 2014, p.
108).
3. Encourage coughing and deep
Cough and deep breathing exercises
breathing. Maintain oxygen
reduce stasis of secretions in the
therapy as prescribed.
lungs and bronchial tree. When
stasis occurs, pathogens can cause
upper respiratory tract infections,
including pneumonia (Gulanick &
Myers, 20143, p. 108).
4. Teach the patient to wash hands
Patients and caregivers can spread
often, especially after toileting,
infection from one part of the body
before meals, and before and
to another, as well as pick up
after administering self-care.
surface pathogens; hand washing
reduces these risks (Gulanick &
Myers, 2014, p. 108).
Evaluation of whether outcome(s) are met / Patient Responses to
interventions:
Unable to evaluate outcome of interventions due to patient being discharged to
ICU.
From what I was able to gather, patient was very verbal about any discomforts.
Because of verbal ability, monitoring for signs on infection would be confirmed by
patients words. If patient did not get discharged to ICU, I wouldve asked her
about her diet and what she normally likes to eat. And then continue to educate

her on why protein and calorie rich foods would be beneficial to her. Also, I would
encourage her to drink fluids because that also helps to prevent infection. I would
also encourage breathing exercises and explain to her why she needs to be doing
them several times a day. From what I witnessed, patient has very good hand
hygiene. She washed her hands often and very thoroughly.
Resources:
Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.). Philadelphia, PA:
Elsevier.

Nursing Dx: Risk for further infection to right foot related to

transmetatarsal amputation.
Expected Outcome: Patient remains free of infection as evidenced by
adequate vascularization at right foot and cessation of necrotic tissue
growth.
Nursing Interventions
Rationales
1. Assess patients temperature and Temperature >= 101.3 F for 48-72
monitor WBC counts.
hours after surgery is related to
surgical stress; after 48 hours,
temperature > 99.8 F suggests
infection. An elevated WBC count is
typically indication of infection
(Gulanick & Myers, 2014, p. 245).
2. Assess the incision and wound for Open wounds should appear
redness, drainage, swelling, and
pink/red and moist, with minimal
increased pain.
serosanguineous drainage. These
wounds are usually packed with
sterile gauze moistened with sterile
saline (Gulanick & Myers, 2014, p.
245).
3. Discuss any weight-bearing
These restrictions prevent skin
limitations and their importance.
breakdown and facilitate proper
wound healing (Gulanick & Myers,
2014, p. 637).
4. Use aseptic technique during
Aseptic technique for dressing
dressing changes.
changes limits the introduction of
pathogens (Gulanick & Myers, 2014,
p. 246).
Evaluation of whether outcome(s) are met/Patient Responses to
interventions:
Patients temperatures were elevated slightly today, getting readings of
100.3F and 98.9F. I asked the patient if he felt hot, but his reply was no.
WBC count was elevated today at 11.89. This is usually indicative of

infection, but Dr. Wong assessed the wound and did not mention any signs
of infection. MD, staff RN, and SN assessed the wound site. There was a lot
of dried blood on the original dressing. Abnormal redness was not present,
drainage was minimal. No swelling, and patient reported very little pain.
Wound bed was pink/red, surrounding skin intact, and no purulent
drainage. Patient got constant reminders today about weight-bearing and
his affected extremity. I think the patient understands that he cannot bare
weight on his foot, and I think he continues to do it or attempt to do it
because hes used to having a foot there. Its a subconscious reaction for
him. He still needs to adjust to the amputation. Aseptic technique was used
during the dressing change. Staff RN and SN did a wet to dry, covering the
wound with gauze, abd pads, and an ACE wrap.
Resources:
Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.).
Philadelphia, PA: Elsevier.
Nursing Dx: Risk for infection related to right groin permacath and history of
recurrent multiple infections. Patient has limited option sites for dialysis.
Expected Outcome: Patient remains free of infection and permacath remains
patent.
Nursing Interventions
Rationales
1. Assess patients understanding of
Assessment provides an important
infections and preventative
starting point in education. Knowledge
measures.
serves to correct faulty ideas (Gulanick
& Myers, 2014, p. 116).
2. Assess patients ability to keep site
Patient may only require assistance
clean, utilizing herself, family
with some self-care measures (Gulanick
members, and/or others.
& Myers, 2014, p. 164).

3. Assess site for signs of infection

(elevated temperature, heat,
redness, swelling, pain).
4. Educate patient on proper hygiene
habits. Encourage patient to
participate in these hygiene habits.
a. Such as washing hands with
soap and water before and
after meals and toileting.
b. Using the toilet whenever
voiding, instead of using the

Family members can play a crucial role

when patient is gathering new
information and/or initiating new
treatments (Gulanick & Myers, 2014, p.
119).
Classic signs of infection are localized
redness, heat, swelling, and pain
(Gulanick & Myers, 2014, p. 107).
Repeated practice by the patient will
help her gain confidence in self-care
ability (Gulanick & Myers, 2014, p. 118).
Hand washing with soap and water
effectively remove microorganisms
from hands (Gulanick & Myers, 2014, p.
108).

brief.

Wounds close to the perineum are at

highest risk for infection caused by
urine or fecal matter. It is often difficult
to isolate the wound from the perineal
area (Gulanick & Myers, 2014, p. 954).
Evaluation of whether outcome(s) are met/ Patient Responses to
interventions:
Patient is able to keep site clean by voiding via the toilet, yet she depends on the
brief. I did not witness the patient wash her hands once while on the floor.
Independence and hygiene habits need to be encouraged. There are no signs of
infection to her right permacath. Constant assessment is needed because patient
has history of multiple recurrent infections to her left thigh, which is why patient
has the permacath in the first place. Education did not occur with patient due to
transport to dialysis and patient sleeping once settled at dialysis.
Outcomes were not fully met. Education is a huge factor in this patients
condition. I think that the nursing staff should focus more on education than they
already do because educating the patient can prevent a lot of future
complications.
Resource:
Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.). Philadelphia, PA:
Elsevier.

Nursing Dx: Self-care deficit related to right sided weakness as evidenced

by inability to bathe and dress self independently.
Expected outcome: Patient identifies resources that are useful in
optimizing autonomy. Patient will safely perform self-care activities.
Nursing Interventions
Rationales
o Assess patients ability to
o Patient is able to complete most
perform ADLs effectively and
ADLs independently. Needs
safely on a daily basis.
assistance with bathing and
o The patient may only need
dressing. Patient needs help
setting up shower (water,
assistance with some selftemperature, adjusting shower
care measures (Gulanick &
head), soap administration
Myers, 2014, p. 164).
(needs several pumps of soap
o Assess the specific cause of each
per shower), and washing her
deficit.
back.
o Different etiological factors
o Deficit is related to patients right
may require more specific
sided weakness that resulted
interventions to enable selffrom AVM to brain.
care (Gulanick & Myers,
2014, p. 164).
o Assess the patients need for
o Patient has no assistive devices
assistive devices.
for bathing or dressing at the
o Assistive devise increase
moment. Needs occupation
independence tin
therapy.
performance of ADLs. OT
has wide range of self-help
devices (Gulanick & Myers,
2014, p. 164).
(For dressing/grooming)
o Encourage use of clothing one
o Patient prefers smaller clothing
size larger.
because of the tighter fit. Doesnt
o A larger size ensures easier
like the clothing to be too loose.
dressing and comfort
o Patient brushed hair
(Gulanick & Myers, 2014, p.
165).
independently but stated it was
o Encourage patient to comb own
tiresome.
hair.
o A one handed task (Gulanick
& Myers, 2014, p. 166).
(For bathing)
o Ensure that needed materials are o Places items all within reach of
close by.
patient with a few exceptions
o Nearby placement of items
such as some towels and fresh
clothes.
conserve energy and
optimizes safety (Gulanick &

Myers, 2014, p. 166).

o Encourage patient to bathe
herself as much as she s capable
of.
o Hospital workers and family
caregivers are often in a
hurry and do more for
patients than needed,
thereby slowing the patients
efforts at regaining
independence (Gulanick &
Myers, 2014, p. 166).
o Plan teaching sessions ahead of
time so the patient has time to
practice tasks before discharge.
o This allows patient to use
new information
immediately, thus enhancing
retention (Gulanick & Myers,
2014, p. 167).
o Instruct patient in the use of
assistive devices as appropriate.
o Information enables patient
to take some control
(Gulanick & Myers, 2014, p.
167).
Evaluation of whether outcome(s)

o Patient wash as much as she

could by herself. Needed
assistance with her back and
feet/toes.

o Plan to teach patient to dispense

soap independently by using
thighs to stabilize bottle and left
hand to pump soap.

o Patient has no assistive devices

for bathing or dressing at the
moment. Needs occupation
therapy.

are met:

Patient is very independent, but needs assistance with ADLs such as

bathing, grooming, dressing, and other small tasks like pouring water from
the pitcher into the cup. As far as bathing goes, I had to help out quite a
bit. Patient very specific about materials needed, such as a shower cap.
Patient needed help turning shower on/off, setting temperature, laying out
floor towels, washing/rinsing back, and pumping soap from bottle onto
wash cloth. For dressing, patient needs help putting feet through legs holes
for bottoms, but can pull everything up onto hips. Shes able to dress top
half but takes some time. She doesnt have any assistive devices which is
strange because I think she could greatly benefit from them. Devices such
as a long brush to scrub back, and some type of device so she can put her
own socks on and get her legs through the leg holes on the bottoms. And
maybe her own shower cap so I dont have to make shift one out of a
plastic bag. I plan to test her independence more tomorrow during her
shower to see if shes able to complete more things alone. Will do some
teaching before shower to see what accommodations we can make.

2nd day, response to shower teaching: I did not give my patient a shower
today because I helped out with another dressing change, administered
medication, and was supposed to watch a PICC insertion. However, I did
tell the patient to practice dispensing soap independently, which she
continued to claim was too hard to do. I also told the nurse aide what I
wanted the patient to work out. I did not get the chance to follow up with
the aide or the patient in regards to how the shower went.
Resource:
Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.). Philadelphia,
PA: Elsevier.

Nursing Dx: Risk for falls related to right sided weakness, assistive
device, visual/hearing difficulties, and cluttered environment.
Expected Outcome: Patient will remain free of falls, will use assistive
device, and have a clean, uncluttered room.
Nursing Interventions
Rationales
o Assess for factors known to
o Patient has right sided weakness
increase risk of falls
which affects her upper and
o Sensory deficits
lower extremities. She has slight
sensory deficits in her ears and
o Impaired vision and hearing
eyes. Patient has a front wheeled
limit the patients ability to
walker, but does not use it.
recognize hazards in the
Despite all these things, patient
environment (Gulanick &
still ambulates independently.
Myers, 2014, p. 65).
o Use of mobility device
o Improper use and
maintenance of mobility aids,
such as walkers, increase the
patients risk for falls
(Gulanick & Myers, 2014, p.
65).
o Disease-related symptoms
o Increased incidence of falls
has been demonstrated in
people with symptoms such
as weakness and fatigue
(Gulanick & Myers, 2014, p.
65).
o Encourage patient to use
o Patient understands the
assistive device
importance of her walker, yet
o Decreased usage of assistive
refuses to use it. Pt doesnt keep
walker set up and open, or within
aids increases the patients
reach.
risk for falls (Gulanick &
Myers, 2014, p. 65).
o Remove as much clutter from
o Patient has a lot of clutter in her,
room as possible. Keep walk ways
included 2 shower chairs and
clear.
extra supplies/equipment (basins,
o Patients who use mobility
bottles, trash cans).
devices are less able to
maneuver around obstacles
in their path (Gulanick &
Myers, 2014, p. 67).
o Instruct the patient and family
o Did not get a chance to talk to
member(s) in what to do after a
patient about what to do in case
fall prompt evaluation of the
of a fall.

consequence of a fall will

facilitate early treatment
(Gulanick & Myers, 2014, p. 68).
Evaluation of whether outcome(s) are met:
Patient is very stubborn when it comes to ambulating with her walker.
Insists that shes only walking a short distance and holds onto things like
the bedside table. Her walker was folded up and put on the ledge near the
window upon entering the room. I opened up the walker and put it next to
her bed within reach. Despite that, patient continued to ambulate without
it. She actually walked around it, which makes it more of an obstacle than
an assistive device. She did have a lot of clutter in her room. I talked to
house keeping so we could get that extra chair out of there as well as some
other equipment. I didnt get a chance to talk to patient and/or family
member about what to do in case of a fall. I think this is something that
should be done because patient is getting ready for discharge and she will
be living with her only family member, her niece, who may not have a lot
of time to devote to patient due to her career.
Resource:
Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.). Philadelphia,
PA: Elsevier.

Nursing Dx: Self-care deficit related to colostomy and urostomy care as

evidenced by stroke causing left sided weakness and decreased fine motor
skills in left hand.
Expected outcome: Patient will be able to care for ostomies via self, help
from family/close friend(s), or from home health nurse.
Nursing Interventions
Rationales
From what I was able to gather, the
patient does not have any family to
help him with his ostomies. He
1. Assess the availability and
claims to have a friend that helps
willingness of family members,
him get his groceries at home, but
friends, and other caregivers to
no one answers the phone when
assist the patient with care after
calling the friend. The patient has a
discharge.
complicated living situation and Im
not sure if he qualifies for a home
health nurse.
Patient claims he uses a table at
home to help change his ostomy
bags, but when trying to
2. Assess the patients ability to
demonstrate in front of SN and
empty and change the ostomy
wound nurse, patient struggling to
pouches.
complete task. Could not do
majority of care because of his
affected extremity.
Patient demonstrates ability to clean
stoma and surrounding skin well.
3. Teach the patient how to care for
May need help with set up (wetting
the stoma and surrounding skin.
napkins to wipe, gathering supplies).
4. Allow at least one opportunity for
a supervised return
demonstration of a pouch change
before discharge from the
hospital, or arrange for home
nursing care.

Not sure about patients discharge

plans, but I dont think hes ready to
go home due to todays
demonstration.

Evaluation of whether outcome(s) are met:

Patient is definitely unable to care of ostomies at this time. Im not sure if
hell even be able to return home if he is unable to care for ostomies or get
someone to help him with it. I dont know his full story, so Im not sure
about his living/financial/insurance situation. Patient seems compliant and
ready to learn, or at least attempt different options for self care.
Resource:

Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.). Philadelphia,
PA: Elsevier.

Nursing Dx: Risk for decreased wound healing related to increased

maceration at wound edges.
Expected Outcome:
Patient will not put any weight on lateral aspect of left foot, decreasing the
risk for maceration and increasing healing properties of wound.
Nursing Interventions
Rationales
1. Assess patients skin integrity,
Patient has maceration present at
noting the color, moisture,
lateral aspect of wound bed on left
texture, and temperature,
foot. Wound bed soft, red/pink and
especially at pressure points.
acceptably moist. Veins and tendons
present. Temperature not assessed.
Surrounding skin remains clean and
2. Keep the skin clean and dry.
dry.
Patient keeps affected foot elevated
on pillows, above the heart. If
affected extremity was not elevated,
3. Elevate affected extremity.
edema could occur and more
drainage would occur. More moisture
can lead to more maceration.
Patient has wound in which lateral
aspect is near the ankle, a pressure
4. Encourage patient to keep
point. Reminded and reinforced the
weight off of pressure points that
instructions of keeping off of that
are close to the wound bed.
part of the heel, because the weight
causes heat and moisture and
maceration, which is going to
prolong the healing time.
Evaluation of whether outcome(s) are met:
Patient is a very compliant, knowledgeable patient. He seems eager to be
discharged but understands why he must remain hospitalized. Patient has
a wound vac, so tissue under the vac is kept clean. Surrounding skin seems
to be kept clean and dry, but it is a very tender area so this might be a
possible reason why it wouldnt get cleansed. Patient is very persistent
with keep affected extremity elevated. He stated understanding of orders
to remain off of macerated side of wound. Only time will tell whether hes
following these orders or not, and the would will show evidence of whether
pressure has been applied or not. If there was pressure, the maceration will
increase. If there was no pressure, maceration will decrease and the
healing would increase.
Resource:
Gulanick, M. & Myers, J. L. (2014). Nursing care plans (8th ed.). Philadelphia,
PA: Elsevier.