Date of Care: February 11, 2025
Pt. Initials: XX CJ |
Admit Date: September 13, 2024 |
Age: 62 years |
Sex: Female |
Diet: Regular diet |
Activity: Sedentary lifestyle, stand with the assistance of two |
Admitting Dx: Necrotizing soft tissue infection |
Equipment/Treatment: Hoyer lift, female external catheter, and wound care kit |
Co-existing Dx & Chronic Problems: Hypertension, morbid obesity, and atrial fibrillation |
Allergies: Vancomycin |
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Anticipated signs and symptoms for ANY client with the above primary disease process ONLY
(Choose 7 of the 10 body systems): |
Potential Risks/Complications from the disease and/or meds
(complete all of these body systems): |
Neurosensory-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
CV/Hematology-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
Immune-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
Integumentary-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
M/S-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
Respiratory-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
GI-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
Endocrine-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
GU/Reproductive-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
Mental Health/PsychoSocial-
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Risks/complications from the disease:
Possible side effects from meds: Interventions for prevention of complications: |
Gordon’s Functional assessment: Please the attached tool to help you complete a Gordon’s assessment. |
Health Perception- Health Management –
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Nutritional Metabolic-
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Elimination-
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Activity/Exercise-
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Sleep/Rest-
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Cognitive/Perceptual-
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Self-perception-
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Role/Relationship-
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Sexuality/Sexual functioning-
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Coping/Stress management-
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Value/Belief system-
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Medication Sheet
Med/Dosage/Route
Frequency (Trade/Generic) |
Action of Drug
(Pathophysiology) |
Why is YOUR Pt. taking this med? | Nursing Implications
1.Teaching statement in quotes 2. Nursing Actions taken |
Evaluation Data
(Proof of meds effectiveness for your pt, use real client specific data) |
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Laboratory Findings and Diagnostic Tests
Date/Test | Norms | Pt. Results | What is the significance of this lab/diagnostic test to YOUR client? |
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If labs/diagnostic tests are not complete, which diagnostics do you think would be important to monitor? |
Nursing Plan of Care
*Put list in priority order.
Recognize Cues: Problems you have identified in your client from assessment data collected | Analyze Data & Prioritize Hypotheses:
Determine what the collected relevant data means and prioritize real complications based off of assessment data |
Generate Solutions: Define the expected outcome for each priority hypothesis. | Take Actions:
Include 5 Nursing actions to assist you in meeting the desired solution. AND include to whom you will delegate the interventions to. |
Evaluate Outcomes: Criteria you as the RN would utilize to evaluate the effectiveness of the action in relationship to achieving the solution. |
New surgical incision of left lateral hip with warmth, swelling & redness | Infection related to break in the first line of defense | Patient will not develop signs or symptoms of infection in the surgical incision of left lateral hip during hospital stay. | 1. Use standard precautions with all cares.
2. Dressing change as ordered using absolute sterile technique. 3. Monitor for signs of early inflammatory response. 4. Monitor caloric intake for adequate nutritional intake to promote wound healing. 5. Monitor vital signs for signs of early inflammation/infection. |
The goal will be met when incision is healed without signs or symptoms of wound infection based on RN evaluation of incision site.
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