You are on page 1of 4

Loyola University Medical Center Critical Care Unit Wound Doctor: Carmina Thornhill Patient: Aaron Brown D.O.

B 12/24/87 Rm: P2211

Physician: Ajihid Botain

ALLERGIES: -CILLINS

Admitting Dx: Stage 3 Pressure Ulcer 4cm x 3m on sacrum with purulent drainage Hx of stage 1 pressure ulcer 3cm in diameter approximately one month ago

Data

Nursing Diagnosis in NANDA Format Impaired tissue integrity, related to impaired physical mobility, as evidenced by stage 3 pressure ulcer 4cm by 3cm on sacrum with purulent drainage.

Goals or Expected Outcomes 1.Experience a wound that decreases in size and has increased granulation tissue and absence of further infection by discharge on 9/01/12 2.Have no further skin breakdown for the duration of his stay in this facility by discharge

Nursing Rationale Intervention s a) Monitor the site of impaired tissue at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. a)Systematic inspection can identify signs of infection early. (Ackley-Ladwig pg.842)

Subjective: -Aarons stated that he feels angry Objective: -Vomiting -Diarrhea -Open stage 3 pressure ulcer approx 4cm by 3cm on sacrum with purulent drainage. -wound infected with MRSA

b) Monitor continence status and minimize exposure of the

b)Implementing an incontinence prevention plan with the use of a skin or cleanser protectant can

Evaluation of Goals and Interventio ns a)Goal Met: 09/01/12 0900 observed no signs of further infection around wound, purulent wound drainage minimal. Wound dressing change at 0945. b) Goal Met: Physician

Revisions Needed

b) Physician orders remain the same

Loyola University Medical Center Critical Care Unit Wound Doctor: Carmina Thornhill Patient: Aaron Brown D.O.B 12/24/87 Rm: P2211

Physician: Ajihid Botain

ALLERGIES: -CILLINS

Admitting Dx: Stage 3 Pressure Ulcer 4cm x 3m on sacrum with purulent drainage Hx of stage 1 pressure ulcer 3cm in diameter approximately one month ago

on 9/01/12

3. Verbalize and understand personal risk factors for impaired skin integrity by 2300 on 08/29/12

impairment site and other areas to moisture from urine or stool, perspiration, or wound drainage.

significantly decrease skin breakdown and pressure ulcer formation.(AckleyLadwig pg 843)

c) Implement a written treatment plan for the topical treatment of the skin impairment site.

c)A written treatment plans ensure consistency in treatment, care and documentation. (Ackley-Ladwig pg. 843)

ordered 14fr Foley catheter to be inserted at 1300 on 08/29/12. Catheter was inserted at 1400 on 08/29/12. Patient is currently on a bowel program 1x a day q am. c)Goal Met: A treatment chart was started on 08/29/12. treatment chart includes: stage of pressure

c) Treatment chart is updated each time a procedure is done to the wound and or the skin is checked. **Nurses need to be inserviced on the proper

Loyola University Medical Center Critical Care Unit Wound Doctor: Carmina Thornhill Patient: Aaron Brown D.O.B 12/24/87 Rm: P2211

Physician: Ajihid Botain

ALLERGIES: -CILLINS

Admitting Dx: Stage 3 Pressure Ulcer 4cm x 3m on sacrum with purulent drainage Hx of stage 1 pressure ulcer 3cm in diameter approximately one month ago

4)verbalize and understand treatment plan for healing of current wound and prevention of further skin breakdown upon discharge on 9/01/12

5. Patient will be turned and repositioned in order to promote adequate

d) Select a topical treatment that maintains a moist woundhealing environment and also allows for absorption of exudate and filling of dead space. e) Do not position the client on the site of

d) Choose dressings that provide a moist environment, keep peri-wound skin dry, and control exudate and eliminate dead space.(Ackley Ladwig pg 843)

ulcer, daily measuremen t of wound and medications and dressing prescribed for wound. (refer to treatment chart for specification s) d) Goal met: Physician ordered wound to be cleansed with normal saline and packed with calcium alginate and covered with a gauze

e) If it is consistent with overall client management goals, turn and position the client every 2 hours, and

way to document their findings. Revision to above: Nurses were inserviced by wound doctor, Dr. Carmina Thornhill on 08/29/12 at 0930 on the correct way to documen t their findings and on proper wound

Loyola University Medical Center Critical Care Unit Wound Doctor: Carmina Thornhill Patient: Aaron Brown D.O.B 12/24/87 Rm: P2211

Physician: Ajihid Botain

ALLERGIES: -CILLINS

Admitting Dx: Stage 3 Pressure Ulcer 4cm x 3m on sacrum with purulent drainage Hx of stage 1 pressure ulcer 3cm in diameter approximately one month ago

circulation and wound healing.

impaired tissue integrity.

transfer the client carefully to avoid adverse effects of external mechanical forces. (Ackley Ladwig pg.843)

dressing, care. irrigate wound and change dressing once a day or whenever saturated or soiled. **Notify physician of any measuremen t or drainage changes. e) Goal Met