SUBJECTIVE Skin Integrity: [x] dry
OBJECTIVE
Comments: ³naa lage koy samad sa akong tuong tiil na dili gaka ayo´
[x] dry [] cold [] pale [] flushed [] warm [] moist [] cyanotic *rashes, ulcers, decubitus (describe size, location, drainage) presence of rashes in entire body, wound has lesions in different sizes, unble to determine specific size
Comments: "medyo mag kiang " kiang ko paglakaw sa asking tuong tiil kay sakit´
[] LOC and orientation : the patient is oriented to the place, date, time, person. Gait: [] walker [] cane [ x] other
[] itching [] other [] denied Activity/Safety:
[ ] convulsion []dizziness
[x] limited motion Of joints Limitation in ability to [ ] ambulate [ ] bathe self [ ]other [x] denied Comfort/Sleep/ Awake: [x] pain Comment ³di ko katulog ug tarong,ga sige ra ko matamata,dili ko comfortable matulog sa hospital´ frequency Remedies) [ ] nocturia [x] sleep difficulties [ ] denied Coping: Occupation: Retiree in Delmonte Inc. (Jr. Supervisor Leadman) Member of household: 6 (six) Most supportive person: R .J .(Wife)
[x] steady [] unsteady ____________ [] sensory and motor losses in f ace or extremities The patient has no sensory or motor losses in face or extremities [ x] ROM limitations: the patient has limited range of motion at right lower extremity [x] facial grimaces [ ] guarding [ ] other signs ________________________________________ [ ] siderail release from signed (60 + years) ____No siderails available______
Observed non-verbal behavior Patient is shy and anxious with his condition especially with female nurses The person and his phone number that can be reached any time Confidential
SPECI AL PATIENT INFORM ATION N/A Daily weight PT/OT N/A 140/80 BP q shift Date ordered
Diagnostic/lab. Exam
Date done
11-17-10
CBC, Blood typing, Chemistry
11-17-10
11-18-10
Cross matching
11-18-10
11-18-10
HGT
11-18-10
Date ordered
I.V. Fluids/Blood
Date Disc.
11-17-10
#1 PNSS 1L@ 10gtts/min
11-18-10
11-18-10
PNSS 1L @ 20gtts/min
11-18-10
11-18-10
#1 Blood Transfusion packed RBC
11-18-10
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type-O (450 ml) 11-23-10
11-24-10
11-26-10
X-ray
Chest X-ray
Tissue Bio psy
11-23-10
11-24-10
For follow u p result
11-19-10
#2 PLR 1L @10gtts/min
11-20-10
#3 PLR 1L @10gtts/min
11-20-10
#2 Blood transfusion ty peO (371ml)
11-21-10
#4 PLR 1L @10gtts/min
11-23-10
#5 PLR 1L @10gtts/min
11-26-10
#1 D5NSS 1L @20gtts/min
11-26-10
#2 D5NSS 1L @20gtts/min
11-20-10
11-20-10
11-20-10
11-21-10
11-23-10
11-26-10
11-26-10
28
VII NURSING CARE PL AN A.
IDEAL NURSING CARE PL AN
OSTEOMYELITIS
NURSING DIAGNOSIS: Impaired physical mobility related to pain or discomfort. EXPECTED OUTCOME: Patient will state relief from pain. Patient will begin to accept limitations imposed by immobility and accompany lifestyle changes. ACTIONS/INTERVENTIONS Encourage patient to verbalize pain and discomfort. Observe for non-verbal cues of pain, including favoring a body part and grimacing. Perform the prescribed treatment regimen for the underlying condition producive pain or discomfort. Encourage patient in active movements by using assistive devices. Implement ROM excersises every shift after pain medication unless medically contraindicated; progress from passive as tolerated. Reposition patient every 2 hours and provide meticoulous skin care. Encouraged patient to verbalize feelings and concerns about his altered state of mobility. y
y
y
RATIONALE
This aid the assessment of the location, quality and intensity of pain.
To assess the effectiveness of the treatment.
To increase the muscle tone of and increase patient¶s feeling and selfesteem.
y
This prevents joint contracture and muscle atrophy.
y
To prevent skin breakdown.
To reduce anxiety and promote
y
compliance.
29
NURSING DIAGNOSIS: Impaired skin integrity related to internal (somatic) and external (environmental) factor.
EXPECTED OUTCOME: patient will exhibit improve or healed lesions or wound. ACTIONS/INTERVENTIONS y
y
y
y
y
Inspect patient skin every shift, describe and document skin condition and report changes. Maintain proper enviromental conditions including room temperature and ventilation. Remind or warned patient not to scrath or tampering with the wound or dressing. Position patient for comfort and minimmal pressure. Change position every at least 2 hours.
RATIONALE
This
provides
effectiveness
evidence of
the
of
skin
the care
regimen.
Providing a comfortable environment promote a sense of well being.
To avoid potential for infection.
This
measures
reduce
pressure,
promote circulation and avoid skin breakdown.
Explain the therapy to patient and family members.
To encourage compliance.
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NURSING DIAGNOSIS: Acute pain related to biological or chemical agent.
EXPECTED OUTCOME: Patient will state and carry out appropriate interventions for pain relief. Patient will decrease amount and frequency of pain medication needed. Patient will express feeling of comfort and relief from pain. ACTIONS/INTERVENTIONS Assess patient¶s signs and symptoms of pain and adminster medication as prescribed. Monitored and record medications effectiveness and adverse effect. Perform comfort measures to promote relaxation such as massage and bathing, repostioning and relaxation technique. y
y
RATIONALE
Assessment allows for care plan modification as needed.
This measure reduce muscle tension ort spasm, redistribute pressure on body parts, and help patient focus on non-pain- related subjects.
y
y
Plan activites with patient to provide distraction such as reading, crafts, television and visit. Help patient into a comfortable position and use pillows to splint or support painful areas as appropriate.
related matters.
To
reduce
muscle
tension
and
spasm and to redistribute pressure on body parts.
y
To help patient focus and non-pain
To minimize or relieve pain.
Apply heat and cold compress
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NURSING DIAGNOSIS: Bone infection related to infection that has migrated to bone tissue.
EXPECTED OUTCOME: Patient response to antibiotic therapy, as evidence by normal WBC, negative wound culture findings. ACTIONS/INTERVENTIONS
y
Assess affected area for signs and
RATIONALE
modification as needed.
symptoms of infection. y
Assessment allows for care plan
Assess lab values, especially WBC
To evaluate further abnormalities.
To aid in establishing diagnosis.
Wound cultures are necessary to
and sedimentation rate. y
Assess bones scan finding.
y
Obtain
appropriate
sensitivities;
blood;
cultures
and;
aspirate
from
identify causative agent.
bone abscess if present.
y
Administer IV antibiotics as ordered.
Aggressive antibiotic treatment is the primary therapy.
y
Provide fluids.
To prevent dehydration in febrile state.
y
Ensure
sterile
technique
during
to prevent close contamination
dressing
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NURSING DIAGNOSIS: Impaired bone tissue perfusion related to continuation infectious process.
EXPECTED OUTCOME: Patient¶s condition of impaired tissue will improves as evidence by decreased redness, swelling and pain. ACTIONS/INTERVENTIONS
y
Apply continuous or intermittent wet
RATIONALE
intensity
of
Discourage rubbing and scratching then provide gloves if necessary.
y
reduce
inflammation.
dressings. y
To
To
prevent
further
injury
and
delayed healing.
Provide medicated soaks in open wound as ordered.
y
y
To treat skin and tissue infections.
To treat infection.
To enhance venous return.
To maximize tissue perfusion.
To prevent further injury.
Administer IV antibiotics as ordered
encourage early ambulation, when possible
y
Elevate
the
legs
when
sitting,
avoiding sharp angulation at the lower extremities.
y
Discourage sitting/standing for long periods,
wearing
constrictive
clothing, crossing legs.
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B.
S
O
A
P
I
E
ACTUAL
NURSING CARE PLAN
³medyo mag kiang-kiang ko paglakaw sa akong toung tiil kay sakit.´
-tingling sensations at wound area -verbalization of pain pain scale: 4/10 -impaired mobility at right leg
Impaired physical mobility related to pain due to the presence of wound.
At the end of 3 hours patient will be able to be independent in performing activities of daily living within capabilities and utilizes energy conservation techniques.
1. Encouraged patient to ask for assistance from significant others 2. Introduced some diversional activities -watching tv -talking -listening to music -reading news pa per 3. Placed a table within patient¶s reach with common necessities. 4. Encouraged patient to elevate the lower leg. 5. Encouraged patient to use cratches 6. Instructed patient to perform passive ROM exercises. 7. Administered pain reliever (Celecoxib) as ordered
At the end of 3 hours of nursing interventions patient was able to be independent and utilized energy conservation techniques.
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S
O
A
-none
-tingling sensations at wound site -complaints of numbness -Hemoglobin result: 112mg/dl -edema ; non-pitting at lower right leg -weak dorsalis pedis pulse
Altered tissue perfusion; peripheral RT decreased oxygen carrying capacity of blood.
At the end of 3 days the patient will be a ble to maintain o ptimal tissue perfusion as evidenced by nor mal Hemoglo bin level and strong peri pheral pulses.
P
I
E
1. 2. 3. 4. 5. 6.
Monitored quality of all pulses. Encouraged frequent ambulation. Instructed to elevate lower leg. Perfor med daily dressing using Dakin¶s solution and co ver with sterile. Instructed patient to avoid scratching the affected part. Discouraged patient in sitting/standing in longer periods without wearing constrictive clothing¶s and crossing legs. 7. Administered anti biotics (Imi pinem) as ordered by the doctor 8. Perfor med blood transfusion 2 ³u´ PRBC as ordered by the doctor
After 3 days the patient was able to achieve a normal hemoglobin level As of CBC result dated 11/20/10 ;123mg/dl
35
S
³binhod lang akong kamot´
-tingling sensation at wound area
O
A
Acute Pain RT tissue injury on right lower leg
At the end of 30 mins. The patient will ver balize reduction of pain.
P
I
1. Encouraged minimal movement of affected part. 2. Intorduced to client some diversional activities ² Watching tv ² Talking ² Reading news pa per 3. Encouraged to perfor m dee p breathing exercises. 4. Provided adequate rest periods. 5. Advised patient to loosen clothing at affected part and avoid tight fit dressings. 6. Administered pain reliever (Celecoxi b) as ordered.
After 30 mins. Of nursing interventions patient¶ pain was reduced.
E
36
S
O
A
³naa lage koy samad sa akong tuong tiil na dili gaka ayo´
-open wound on the lower right leg -WBC result
Infection RT ; inadequate primary defenses, broken skin Secondary defenses; immunocompromised
At the end of 12 hours the patient will be free from infection as evidenced by a bsence of fever .
P
I
E
1. Instructed patient to do pro per hand washing before and after handling the wound. 2. Handled the wound ase ptically during dressing 3. Advised patient to discard the soiled dressing pro perly in the a ppro priate trash bin. 4. Maintained isolation technique 5. Administered anti biotics(Imi pinem) as ordered 6. Administered Calcium Ascor bate as ordered
After the intervention was done, the goal was met. The patient was able to stay afebrile throughout the whole shift.
37
S
O
A
P
³di ko katulog ug tarong,ga sige ra ko mata- mata,dili ko comfortable matulog sa hospital´
-Yawning -sunken eyeballs -complaints of lack of sleep
Disturbed Sleeping Pattern RT environmental stimuli
At the end 12 hours of nursing interventions, the patient will be able to report improvement in sleep/ rest pattern.
1. Advised patient to wear eye patch. 2. Instructed patient to avoid drinking caffeinated beverages.
I
3. Encouraged patient to use some relaxation techniques e.g. music 4. Advised patient to continue with bedtime rituals e.g. drinking hot milk, and reading books. 5. Provide patient adequate rest periods.
E
After the nursing interventions, the goal was met, the patient verbalized improvement in sleep pattern.
38
VIII. REFERR ALS AND FOLLOW-UP MEDICATION Instructe patient to continue home medication as ordered by the physician. Taught the appropriate dosage, timing, therapeutic effect and possible side-effects of the medications and evaluate the client¶s knowledge and understanding of the proper regimen.
Instructed to take the medications religiously per doctor¶s order. Such as Calcium Ascorbate 1 capsule two times a day; Clelecoxiib 20 mg 1 capsule twice daily for pain
EXERCISE
Encouraged to continue active exercises within cardiac tolerance.
Instructe to resume activity of daily living with minimal assistance then gradually he¶ll regain independence.
Instructe the patient to have adequate rest period at their home, limit of activities that exhaust him and could enhance complications.
Limit stressful activities as much as possible.
Instructed to keep the wound clean and dry.
Instructed to perform regular wound dressing.
OUT PATIENT (CHECK-UP)
Instructed to have follow-up check-up at Puerto community Hospital 1 week after discharge to his physician for additional instructions and for continuous therapy.
Instructed client to report any signs of fever or reoccurrence of the condition to his physician as soon as possible.
DIET
Encouraged to maintain prescribed diet low salt, low sugar diet.
Instructed to increased foods high in protein such as meat, fish and vegetables.
Encouraged to increased foods high in vitamin C such as orange and pineapples and other foods that give energy. 39
IX. EVALUATION AND IMPLICATIONS
This care study was made a beneficial tool to us as a nursing student¶s. To learn from each cases we handle and how to intervene to such diseases if ever we encounter one. After conducting this care study, we were able to appreciate more the essence of utilizing the nursing process in the care and management of our patient. It was indeed a tough job on conducting this study yet, it gave us a big impact regarding how useful it is in our chosen profession. Nursing really demands a tender loving care attitude. It demands patience and it is calling that cannot be merely taken for granted. This study will serve as a reference material in rendering competent care to our clients especially to those with similar situation. Through this, we will be able to develop our knowledge as well as our skills and attitudes in applying the prescribed procedure to improve the health status of the patient. This serves as an evaluation guide on how far we have gone through in the management of our client¶s health. Moreover, this care study taught us to stand on our own by not depending on others just to make this. This provides us students, a big learning regarding on how well we take care of or patients in the real clinical setting. Most of all, this study teaches the students to provide clients care more efficiently and competently to achieve an effective and quality nursing care. The case study paved the way for the students to identify and determine issues related to Osteomyelitis. Through this, the importance of following treatment regimen must be exercised to prevent complications. This study provided the nursing students with essential information on disease prevention, health promotion, and health maintenance.
40
IX. EVALUATION AND IMPLICATIONS
This care study was made a beneficial tool to us as a nursing student¶s. To learn from each cases we handle and how to intervene to such diseases if ever we encounter one. After conducting this care study, we were able to appreciate more the essence of utilizing the nursing process in the care and management of our patient. It was indeed a tough job on conducting this study yet, it gave us a big impact regarding how useful it is in our chosen profession. Nursing really demands a tender loving care attitude. It demands patience and it is calling that cannot be merely taken for granted. This study will serve as a reference material in rendering competent care to our clients especially to those with similar situation. Through this, we will be able to develop our knowledge as well as our skills and attitudes in applying the prescribed procedure to improve the health status of the patient. This serves as an evaluation guide on how far we have gone through in the management of our client¶s health. Moreover, this care study taught us to stand on our own by not depending on others just to make this. This provides us students, a big learning regarding on how well we take care of or patients in the real clinical setting. Most of all, this study teaches the students to provide clients care more efficiently and competently to achieve an effective and quality nursing care. The case study paved the way for the students to identify and determine issues related to Osteomyelitis. Through this, the importance of following treatment regimen must be exercised to prevent complications. This study provided the nursing students with essential information on disease prevention, health promotion, and health maintenance.
40
