Central Maine Community College ADN Program Nursing Process Sheet/2nd year

Assessment/Nursing Dx

Planning/Long & Short Term Goals

Interventions/Nursing Action

Scientific Rationale

Evaluation

Impaired tissue integrity related to inflammatory process damaging skin and underlying tissue, secondary to cellulitis, manifested by pain, redness, swelling, warmth of site, and fever

LTG: Client will have no complications from cellulitis or hospital stay by discharge.

STG1 Nurse will monitor redness, swelling, and warmth and compare to boundaries marked by previous shifts. Nurse will administer antibiotics

STG1. Systematic inspection can identify impending problems early (akley)

STG1 Met Patient showed improvement of signs and symptoms of infection. This included a decrease in warmth and redness and a stable oral temperature within the normal range.

Administering antibiotic therapy on time increases its efficacy (potter)

STG1:Client will show improvement of s/sx of infection by end of shit

STG2 Nurse will monitor meal consumption and encourage >75% of food consumption at all meals

STG2:Client will maintain adequate nutrition throughout shift

Make food available as desired between early evening and breakfast.

STG2 Studies show that patients who leave 25% or more of food uneaten at most meals do not consume adequate protein amongst other nutrients. Adequate nutrients are important for healing, especially in the immunosuppressed patient. (Akley) Having food available 24 hours as desired, can increase nutritional intake. (akley)

STG2 Met Patient consumed >75% of meals throughout shift. He understood the need of adequate nutrition not only to promote healing but also in regards to his immunosuppression.

Prepare the client for meals. Clear unsightly supplies and excretions. Avoid invasive procedures before meals.

A pleasant environment helps promote intake. (Akley)

Central Maine Community College ADN Program Nursing Process Sheet/2nd year

STG 3: Assess pain level in a client using a valid and reliable selfreport pain tool, such as the 0-10 numerical pain rating scale. Nurse will Administer supplemental opioid doses as ordered to keep pain at a tolerable level.

STG3: Single-dimension pain ratings are valid and reliable as measures of pain intensity level. (akley) STG3 Partially met Patient was apprehensive to take his prescribed opioids at first which increased his pain level to a 6. Although he used the pain scale he has a hard time deciding if he wanted any medication for pain control. A modification to this plan of care would be to do more educating on the use of prn opioids for pain and the reasoning behind treating pain prior to it becoming unbearable.

STG3 Client will report a tolerable level of pain throughout shift.

An order for prn supplementary opioid doses between regular doses is an essential backup. (Akley)