Katie Wilson

Nursing Care Plan

This study source was downloaded by 100000833331451 from CourseHero.com on 07-11-2022 02:42:03 GMT -05:00
 Nursing
Diagnosis
1) Acute Pain related
to surgery as
evidenced by self
reported pain level
of an 8, performing
ADLs slowly, and
grimacing facial
expressions.
2) Ineffective
peripheral tissue
perfusion related to
immobility and
diabetes as
evidenced by absent
pulses, color does
not return to leg on
lowering it, and pain
in extremity
3) Risk for infection
related to invasive
procedures
This study source was downloaded by 100000833331451 from CourseHero.com on 07-11-2022 02:42:03 GMT -05:00 have an increased
Goal Outcomes
1) Relief of 1a) Client will use self
pain report to identify a pain
level of 3 by end of the day
2) Adequate 1b) Client will perform
tissue activities of recovery or
perfusion ADLs easily in 3 days
1c) Client will state ability
3) Free of to obtain sufficient
infection amounts of rest and sleep
in 2 days time
2a) Client will demonstrate
adequate tissue perfusion
evidenced by peripheral
pulses, warm dry pink skin
as soon as possible.
3a) Client will maintain
white blood cell count and
differential within normal
limits while in the hospital
3b) Client will remain free
from symptoms of
infection while in the
hospital.
3c) Staff will maintain a
clean environment each
visit with client.
3d) Staff will identify signs
and symptoms of infection
Interventions
1a(i) Assess pain intensity
level in client using a valid
and reliable self report tool
1a(ii) Obtain prescription for
a non-opioid analgesic for
mild to moderate pain and an
opioid analgesic if indicated
for moderate to severe pain
1b(i) Prevent pain by
administering analgesia
before patient care or activity
that could cause discomfort.
1b(ii) Assess the client for
pain routinely; during vitals,
activity and after giving pain
medication.
1c(i)Administer supplemental
analgesic doses/medication to
keep the patient’s pain level at
or below comfort/function
level
2a(i) Monitor peripheral
pulse, if new onset of loss of
pulses occurs contact doctor
immediately.
2a(ii) Assess for pain in
extremity
2a(iii) Recognize that elderly
have increased risk of
developing a pulmonary
embolism.
3a(i) Note and report
laboratory values.
3b(i) Observe and report signs
of infection such as redness,
warmth, discharge, and
increased body temperature.
3b(ii) Recognize that
chronically ill geriatric clients
susceptibility to infection.
Rationale
1a(i) Self reported pain is the
most reliable indicator of pain
presence
1a(ii) They are first line drugs
to treat mild to severe acute
pain
1b(i) preventing pain before
an activity that may trigger
worsened pain will motivate
the patient to attempt activity
1b(ii) Acute pain should be
reliably assessed at rest and
during movement
1c(i) An order for PRN
analgesic doses between
regular doses is essential to
providing comprehensive pain
management.
2a(i) The loss of a pulse is
symptom of arterial
obstruction which can result
in loss of that limb.
2a(ii) Staff will know if
nervous feeling is still present
in the limb.
2a(iii) Prevalence of PE with
age increases.
3a(i) An increase of WBCs
indicates an infection and
needs to be managed
appropriately
3a(i) While white blood cell
count may be within normal
range, an increased number of
immature bands may be
present.
3b(i) Change in mental status,
fever, shaking, chills, and
hypotension are indicators of
infection and sepsis.
 Nursing Care Plan

Patient History:
History of schizophrenia and suicidal ideations; currently on suicide precautions with a 1:1 sitter
Patient has diabetes and hypertension
Stent placed in kidney, came into hospital with infection from stent.
Nephrectomy with JP drain
Indwelling Foley catheter in place
Possible DVT in right leg

Abnormal Lab Values:

This study source was downloaded by 100000833331451 from CourseHero.com on 07-11-2022 02:42:03 GMT -05:00
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