SAULT COLLEGE OF APPLIED ARTS AND TECHNOLOGY

Care Plan

Code Status __DNR___ VS BP: 130/70, PR- 105, RR- 16, T-36.0___ Wt __99.2 KG__
Admitting Diagnosis UROSEPSIS / AKI______ Allergies ______CODEINE______ Diet _REGULAR DIET___ IV _N/A____ LBM 12/11/22__
Surgical Intervention __S/P TURP__________Type of Anesthesia BG _________/___Oxygen ____ROOM AIR__ O2 Sat ___96%_____
________________________
Tubes ___IFC_____ Dressing ____HYGEOL, INADINE_____ Isolation
Coexisting Illness(es) __HTN, BPH WITH RECENT TURP,NIDDM______ _CONTACT/ DROPLET_
Activity _ Mobility level C, Lift/Transfer_ ___ Lift/Transfer DEPENDENT Level
of Risk for Falls _HIGH
Other ___POSSIBLE TRASFER TO ARCH TODAY____________

ASSESSMENT PLANNING
Behaviour/Responses/Findings Nursing Interventions EVALUATION
Nursing AMB/AEB Goal
Diagnosis

Subjective:
”back discomfort and pain from
staying still for a long time.”
Objective:
- necrotic tan base with a small
patch of black necrosis
- solid pressure injury to mid-
spine, and no open or draining
areas
- pressure injury to the buttocks
that is irregularly shaped
- yellow adherent slough at the
base, limited drainage, and
pink, painful skin around the
wound
Impaired skin as evidence by The client will have a - Assess the patient's The patient's wound
integrity related moisture, pain, decreased risk and degree of sensitivity. looks to be dry and
to immobility soreness, and additional degradation to be aware of the free of drainage or
pressure damage of skin integrity after 6 patient's ability to purulent debris after
to the sacrum. to 8 hours of nursing experience pain or 8 hours of nursing
involvement discomfort. interventions.
administering
painkillers that have
been prescribed.
- Apply barrier cream
to the affected area
and practise proper
perineal hygiene to
check for bowel and
bladder incontinence.
- Observe for infection
symptoms like a warm
sensation to the touch
V/s: BP: 130/70, PR- 105, RR- and take note of any
16, T-36.0 odours or exudate
that may be present.
- Promote good wound
care. 
- Repositioning
frequently, at least
every two hours. in
order to relieve
pressure on the
afflicted area and
surrounding bony
prominences.

- Ensure proper wound

care, including
thorough cleansing
and dressing.
- Utilize the proper or
advised pressure-
relieving tools, such
as trochanter rolls
and air mattresses.
- If necessary,
recommend the
physical therapy
team. Encourage
doing manageable
exercises and getting
out of bed to sit on a
chair.
- Promote healthy
eating. Working with
a dietitian, providing
high protein and fluid
intake as needed.
 ASSESSMENT PLANNING

Behaviour/Responses Nursing Interventions EVALUATION

(data collection information and
Nursing Diagnosis AMB/AEB Goal
(including time frame)
observations)
Notes:

SBAR: