BSN 2020

NURSING PROCESS CARE PLAN

Student: ___
Date : 6/12/20

NURSING DIAGNOSIS: Risk for infection r/t right total knee arthroplasty as evidenced by positive MRSA culture

PRIORITY # 1
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION
Subjective and Objective Data 1 Client Goal Interventions Actual Completion of Nursing Goal Evaluation
Subjective Objective (Goal must be timed and (3 Nursing Interventions with Interventions (met, not met, partially met
measurable) SMART Rationale and Reference for each) and explanation)
Patient states, “I Patient’s history of Patient will remain free 1) Perform all care with proper 1) Followed proper Goal has been met. Patient
really don’t know MRSA places him from infection and use of personal protective procedures and shows no s/s of infection.
how to treat the at greater risk for receive proper care and equipment and adhere to techniques when Proper care was given in
wound at home”. infection. education of wound care hospital policies regarding performing wound accordance with hospital
Patient’s limited throughout 12 hour shift. contact precautions and care and reviewed policy. Patient was educated
knowledge of MRSA. This greatly reduces hospital policies regarding wound care and
wound care places the risk of infection for the before going into showed understanding by
him at greater risk patient as well as the spread patient’s room stating what they had to do.
for infection. of infection and MRSA 2) Assessed patient every
outside of the patient’s 2 hours. Documented
room. vitals and noted
2) Assessment of vital signs, everything was
wound, and skin integrity normal. There were no
every 2 hours. This is to s/s of infection
constantly observe and note 3) Taught patient how to
if there are s/s of localized properly care for
or systemic infection. wound, how to make
3) Educate patient about proper necessary
wound care, recognizing s/s observations and
of infection, and the know when to seek
importance of adhering to care, and the
antibiotic regimen. This is to importance of
prevent further finishing the
complications and so the prescribed antibiotics.
patient will be able to care .
for themselves at home.

5/2020 SHM
 BSN 2020

* Cite all interventions/rationales per APA format

NURSING DIAGNOSIS: Knowledge Deficit r/t unfamiliarity with information resources on MRSA as evidenced by questions on how
MRSA may affect his recovery

PRIORITY # 2
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION
Subjective and Objective Data 1 Client Goal Interventions Actual Completion of Nursing Goal Evaluation
Subjective Objective (Goal must be timed and (3 Nursing Interventions with Interventions (met, not met, partially met
measurable) SMART Rationale and Reference for each) and explanation)
Patient states, Patient has limited Patient will understand 1) Assess patient’s readiness 1) Patient stated they Goal has been met. Patient
“I’ve had MRSA knowledge of what the implications of and willingness to learn and wanted to be taught was able to relay back
for 3 years but I MRSA is and how MRSA in the healing set a time to teach. When after lunch because information that was taught
don’t understand it may impact the process of surgical the patient is ready to learn, they don’t like to learn and states they understand
what that has to recovery process. wound by the end of 12 that is when the teaching when hungry. what MRSA is and how it can
do with my hour shift. will be most effective. 2) Taught patient about affect the recovery process.
recovery”. 2) Educate patient about MRSA and they
MRSA and how to understood what
effectively manage MRSA MRSA was and the
to prevent additional risk of importance of
infection r/t surgical managing MRSA.
incision. 3) After teaching, patient
3) Provide patient with was provided with
resources and print outs so pamphlets and website
that they can refer back to resources regarding
the informational sources if MRSA
they forget anything
regarding MRSA

5/2020 SHM
 BSN 2020

* Cite all interventions/rationales per APA format

References

Taylor, C., Lynn P., Bartlett, J. L. (2018). Fundamentals of nursing (9th ed.). Wolters Kluwer. Retrieved from

https://coursepoint.vitalsource.com/#/books/9781975101336/

5/2020 SHM