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Nursing Problem (1st)
Assessment
Goals
Interventions with Rationales (I: Intervention; R: Rationale)
Evaluation
Controlling body temperature: Hyperthermia related to wound infection
Subjective:
- Matt had treated the wound himself by bathing it in vinegar and water
- His daughter discovered the left knee wound has been getting worse today
Objective:
- Abnormal vital sign: 38.9ºC in oral temperature
- Left knee wound back assessment: 2 x 2.5cm, wound bed is yellow, small amount of yellow-greenish discharge, swelling and redness on left leg
Goal:
After 3 days of effective nursing intervention, his body temperature will lower down to normal levels
Desired outcomes:
- His body temperature will be within a normal range which is below 38.0ºC and maintained stable during hospitalization
- His wound will decrease in size and have increased granulation tissue with absence of redness, swelling and purulent discharge
- He will demonstrate the understanding of measures to protect and heal the wound
For hyperthermia
- Assess and monitor his oral temperature every 4 hours. Utilize same methods of temperature reading with each measurement (R: Hyperthermia is a systemic manifestation of inflammation and may indicate the presence of infection; Helps to evaluate efficacy of treatment. Consistency in methods allows for accurate data collection and correlation.) https://nurseslabs.com/impaired-tissue-integrity/ Delmar’s Geriatric Nursing Care Plans, , 1 w (Sheree Comer)
- Administer Panadol tablet 500mg every 4 hours if temperature is greater than 38.0C (R: This type of drugs affects the hypothalamic control center to reduce elevated temperature.) Delmar’s Geriatric Nursing Care Plans, , 1 w (Sheree Comer)
- Encourage fluid intake up to 3-4L/ day, unless contraindicated (Increases in body temperature multiply insensible fluid losses by 10% for every 1ºC increase in body temperature, which result in dehydration which inhibits wound healing.) Delmar’s Geriatric Nursing Care Plans, , 1 w (Sheree Comer)
For wound infection
- Examine and monitor the wound at least once daily; note and document changes in appearance, odor, or quantity of drainage (R: Identifies the presence of granulation tissue indicating healing.)
Nursing Care Plans
- Obtain routine cultures (R: Repeat periodically to evaluate for effectiveness of antimicrobial therapies)
Nursing Care Plans
- Give Augmentin tablet 375mg three times a day (R: It treats infections caused by bacteria by fighting bacteria in the body and helping to prevent certain bacteria from becoming resistant to amoxicillin.) https://www.drugs.com/augmentin.html
- 0.9% normal saline solution dressing to left knee wound daily (R: It can irrigate the wound by keeping viable granulation tissue, reducing the number of microorganisms and not triggering sensitive responses.)
Nursing intervention
- Instruct he and his daughter in the proper care of wound including hand washing, wound cleansing, dressing changes, and application of topical medications (R: Accurate information increases the patients ability to manage therapy independently and reduce the risk for infection.) https://nurseslabs.com/impaired-tissue-integrity/
After 3 days of nursing intervention,
- His body temperature is within normal range and maintained stable
- His wound has a decrease in size with minimized purulent discharge
- He is able to demonstrate the understanding of measures to protect and heal the wound
Nursing Problem (2nd)
Assessment
Goals
Interventions with Rationales (I: Intervention; R: Rationale)
Evaluation
Mobilizing: severe pain on back and left leg related low back pain and wound infection
Subjective:
- He complained of severe pain on back and left leg.
Objective:
- Pain score: 8/10
- Left knee wound back assessment: 2 x 2.5cm, wound bed is yellow, small amount of yellow-greenish discharge, swelling and redness on left leg
Goal:
His pain score will return to the normal range during hospitalization
Desired outcomes:
- His pain score will lower down to less than or equal to 3 out of 10 which indicates mild pain or even no pain.
Pain score
- He will report improvement of back pain and be able to get out of bed without assistance
For overall
- Assess and monitor the pain characteristics every 6 hours including quality and severity (R: It helps determine the effectiveness of pain control measures. If the patient demands pain medications more frequently, a higher dose may be needed.) https://nurseslabs.com/acute-pain/
- Assess for signs and symptoms relating to pain including BR and HR every 6 hours (R: Attention to associated signs may help the nurse in evaluating pain. An increase in BP, HR, and temperature may be present in a patient with pain.) https://nurseslabs.com/acute-pain/
- Give Tramadol tablet 50mg every 6 hours (R: Helps in moderate to moderately severe pain). Tramadol. For low back pain
- Apply an ice pack to area every 4 hours (R: Helps quiet painful inflammation or muscle spasms) https://health.clevelandclinic.org/back-pain-your-spine-and-father-time/
- Collaborate with physicians to do physical therapy (R: Helps patient to gain strength, and strengthening patients back and abdominal muscles) https://health.clevelandclinic.org/back-pain-your-spine-and-father-time/
- Assist him to maintain activity limitations, promote comfort, and educate the patient about the health problem and appropriate exercises (R: It is nurses responsibility to ensure that the patient understands the type and frequency of exercise prescribed, as well as the rationale for the program if there are muscle-strengthening and stretching exercises in the management plan.)
Clinical Companion to Medical-Surgical Nursing – E-Book
- Assess the patients use of body mechanics and offer instruction in sleeping that could produce back strain and a firm mattress is recommended (R: It produces excessive lumbar lordosis, placing excessive stress on the lower back in a prone position.)
Clinical Companion to Medical-Surgical Nursing – E-Book
For wound pain
- Refer to wound infection in 1st Nursing Problem
- His pain score has lowered down to 5 out of 10
- He reports improvement of back pain, but some assistance is still needed to get out of bed. Continue treatment is required
Nursing Problem (3rd)
Assessment
Goals
Interventions with Rationales (I: Intervention; R: Rationale)
Evaluation
Maintaining a safe environment: Risk for fall related to poor vision and limited mobility secondary to low back pain
Subjective:
- He complained of severe pain on back and left leg, some assistance was needed to get out of bed.
Objective:
- Recent fall episode: three days ago
- Morse Fall Scale: 50(high fall risk)
- His age: 65(high risk group)
Goal:
He will be free from any falls during hospitalization and after discharge
Desired outcomes:
- He will not fall during hospitalization
- The problem of low back pain will be alleviated with the pain score lowers down to normal range
- He will report improvement of back pain and be able to get out of back without assistance
- The vision will be improved by using adaptive devices.
He and his daughter will identify strategies to increase safety and prevent falls at home before discharge
For risk for fall
- Assess conditions that can increase the patients level of fall risk, such as changes in mental status, balance and medications every shift (R: Helps evaluate effectiveness of fall precautions) https://www.nursebuff.com/nursing-care-plan-for-elderly/
- Provide signs or secure a wristband identification to remind healthcare providers to implement fall precaution behaviors (R: Signs are vital for patients at risk for falls. Healthcare providers need to acknowledge who has the condition for they are responsible for implementing actions to promote patient safety and prevent falls) https://nurseslabs.com/risk-for-falls/
- Transfer the patient to a room near the nurses station (R: Nearby location provides more constant observation and quick response to call needs) https://nurseslabs.com/risk-for-falls/
- Respond to call light as soon as possible (R: This is to prevent the patient from going out of bed without any assistance) https://nurseslabs.com/risk-for-falls/
- Guarantee appropriate room lighting, especially during the night (R: Patients, especially older adults, has reduced visual capacity. Lighting an unfamiliar environment helps increase visibility if the patient must get up at night) https://nurseslabs.com/risk-for-falls/
- Bed and chair alarms must be secured when patient gets up without support or assistance (R: Audible alarms can remind the patient not to get up alone. The use of alarms can be a substitute for physical restraints) https://nurseslabs.com/risk-for-falls/
- Evaluate patients medications and how they can cause falling accidents (P: Identify drug interactions and side effects that can compromise the patients safety) https://www.nursebuff.com/nursing-care-plan-for-elderly/
For poor vision
- Assess the patients ability to see and perform activities once a shift for any more deterioration (R: Check for any changes affecting the patients visual acuity) https://nurseslabs.com/macular-degeneration-nursing-care-plans/
- Collaborate with ophthalmologist to have vision check (R: Determines the exact vision problem and Give proper treatment)
- Inform patient the advantage of wearing eyeglasses and to have these checked regularly (R: Hazard can be reduced if the patient uses appropriate aids to promote visual orientation to the environment. Visual impairment can greatly cause falls) https://nurseslabs.com/risk-for-falls/
- Encourage patient to see an ophthalmologist at least yearly (R: Can monitor progressive visual loss or complications. Decreases in visual acuity can increase confusion in elderly patient) https://nurseslabs.com/2-cataracts-nursing-care-plans/
For low back pain
- Refer to low back pain in 2nd Nursing Problem
- He does not fall during hospitalization
- The pain score has lowered down to 5 out of 10 and the problem of low back pain has been alleviated, but still requires continue treatment
- He reports improvement of back pain, but some assistance is still needed to get out of bed. Continue treatment is required
- The vision has been improved by wearing eyeglasses
- He and his daughter are able to identify strategies to increase safety and prevent falls at home before discharge
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