Beruflich Dokumente
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Student Name:__Rachel Smith______________ Client’s orders: Include all orders Outcomes: For every order,
Date of Assignment:_2-22-11_____________________ Treatments, meds, labs results and provide the client’s outcome
Clinical Instructor:____Raatz____________________ nursing orders Provide objective and subjective
Clinical Area:_3W_____________________________ data to support your conclusions.
1) Risk for infection Short-Term Goal: 1)Assess for MD, RN The patient’s fever
related to pressure The patient will see presence, existence decreased to 98.1 by the
a decrease in fever of, and history of end of the shift, and she
sore wound and
of 1-2 degrees F risk factors such as did not develop any signs
recent surgical and will not open wounds and of infection.
incision as evidence develop any signs abrasions; Each of
by low lymphocyte of infection by the these examples Patient was not
levels, elderly end of shift. represent a break in discharged during the
compromised the body’s normal shift. However, the
Long-Term goal: first lines of defense patient was able to tell
immune system,
The patient will not (Gilliespie 2009). me how to change her
decreased circulation have a normal 2) Monitor white wound dressing and
and sensation to temperature of 98.6 blood count apply the appropriate
extremities, three IV and normal WBC (WBC).--Rising topical treatments and
accesses, left arm AV lab work levels, WBC indicates state the importance of
graft, and slight and the patient will body’s efforts to hand washing to prevent
be able to repeat combat pathogens; infection of her open
fever of 99.8 at
two ways to normal values: >. wounds.
beginning of shift. prevent infection Very low WBC
by the end of (neutropenia <1000)
discharge. indicates severe risk
for infection because
patient does not have
sufficient WBCs to
fight infection. In
elderly patients,
infection may be
present without an
increased
WBC(Gilliespie
2009).
3) Monitor the
following for signs
of infection:
Redness, swelling,
increased pain, or
purulent drainage at
incisions or injured
sites (Hemorrhoid
incision and left
upper buttock
pressure wound).
Any suspicious
drainage should be
cultured; Levaquin
should be
administered as
ordered per
physician to prevent
infection(Gilliespie
2009).
4)Asses Fever. Fever
of up to (100.4° F)
for 48 hours after
surgery is related to
surgical stress; after
48 hours, fever
above (99.8° F)
suggests infection;
fever spikes that
occur and subside
are indicative of
wound infection;
very high fever
accompanied by
sweating and chills
may indicate
septicemia(Gilliespie
2009) .
5) Assess nutritional
status, including
weight, history of
weight loss, and
serum albumin.
Patients with poor
nutritional status
may be unable to
muster a cellular
immune response to
pathogens and are
therefore more
susceptible to
infection.
4) Maintain or teach
asepsis for dressing
changes and wound
care, catheter care
and handling, and
peripheral IV and
central venous
access management.
The patient should
know to change the
dressings of her
wound every day
and to look for
redness and purulent
discharge during the
dressing. The
patient should not
bathe, but take
showers and wash
the wound lightly
with soap and water.
6) Encourage intake
of protein- and
calorie-rich foods.
This maintains
optimal nutritional
status to be able
maintain
homeostasis and be
able to potentially
fight
infection(Gilliespie
2009).
7) Administer or
teach use of
antimicrobial
(antibiotic) drugs as
ordered.--
Antimicrobial drugs
include antibacterial,
antifungal,
antiparasitic, and
antiviral agents
(Patient prescribed
calcipotriene topical
ointment and
clobetasol topical
ointments). All of
these agents are
either toxic to the
pathogen or retard
the pathogen’s
growth.
MD, RN, PT
2. Risk for falls The patient asked for
Short-Term Goals : assistance and used
related to impaired
Patient will call for walker for toileting
joint mobilization, assistance and use needs, and did not fall
history of falls, 2-day walker for toileting during the shift. The
post-op surgical needs and will be patient felt comfortable
procedure as toileted otherwise having the two side rails
evidence by every 2 hours to up as she slept which is
prevent fall 1) Remove excess an additional intervention
assistance with
preventions during equipment/supplies/ for the nurse to
walker for ADL’s, 21 shift. furniture from rooms implement during the
score Braden scale & hallways(Mosby shift.
indicating high risk Long-Term Goals: 2011).
fall precautions, and The patient will The patient knows to call
continue to toilet 2)Coil and secure for assistance and use the
unsteady gait and
every 2 hours and excess electrical and walker for all ADL’s,
balance. ask for assistance telephone and she knew to clear all
for rising from the wires/cords(Mosby hallways and doorways
bed or chair. The 2011). when she got home. The
patient will be able patient did not have any
to give two reasons 3)Clean all spills in falls before her
to prevent them patient room or in discharge.
from falling by hallway
discharge. immediately(Mosby
2011).
4)Place a signage to
indicate wet floor
danger(Mosby
2011).
5) Keep bed in
lowest position
during use unless
impractical (when
doing a procedure on
a patient) (Mosby
2011).
6) Keep floors
clutter/obstacle free
(especially the path
between bed and
bathroom/commode)
(Mosby 2011).
9)Encourage
patient/family to call
for assistance as
needed (Mosby
2011).
10)Assure adequate
lightening especially
at night(Mosby
2011).
14) Supervise/assist
bedside sitting,
personal hygiene and
toileting as
appropriate(Mosby
2011).
15)Establish
elimination schedule
and use of bedside
commode if
appropriate (Mosby
2011).
References
Gillespie, L. (n.d.). Interventions in preventing falls for the elderly in the community. Interventions for Fall and Infection that
Follows. Retrieved February 27, 2011, from http://www.casorezzo.eu/ama/caduta/docu/cochrane.pdf
Mosby, B. . "EHS: Nursing Care Plans Risk for Infection." EHS: Nursing Care Plans. Guanlick and Myers, 1 Jan. 2006. Web.
27 Feb. 2011. <www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/Constructor.cfm>.