WACHEMO

UNIVERSITY
COLLEGE OF MEDICINE AND
HEALTH SCIENCES
DEPARTEMENT OF SURGICAL
NURSING

PATIENT’S CAREPLAN ON ACUTE

OSTEOMYELITIS +SA
May 9,2023 BY SURGICAL NURSING STUDENTS
NAME AND ID NUMBER

o Dear Taye........12002346

May 9,2023 BY SURGICAL NURSING STUDENTS

NURSING COMPREHENSIVE CLIENT
ASSESSMENT
 Full name: Misgana Kassa
 Age: 15
 Sex:Male
 MRN: 823220
 ADRESS: Hosanna
 Source of information: Her self
 Source of referral: Home

May 9,2023 BY SURGICAL NURSING STUDENTS

CONT…
 Hospital: WUNEMMCSH
 Ward:Ortho Ward
 Medical diagnosis:Acute chronic
osteomyelitis+SA
 Date of admission: 22/07/2015e.c

May 9,2023 BY SURGICAL NURSING STUDENTS

CONT…
 Nationality: Ethiopian
 Ethnic Group: Hadiya
 Language: Hadiyisa
 Marital Status: single
 Religion: Protestant
 Occupational Status: student

May 9,2023 BY SURGICAL NURSING STUDENTS

PATIENT`S SUPPORT
 Name :His mother
Relationship: His mother
Address: Hossana

May 9,2023 BY SURGICAL NURSING STUDENTS

DOMAINS OF NURSING
DIAGNOSIS

May 9,2023 BY SURGICAL NURSING STUDENTS

1. HEALTH PERCEPTION AND
MANAGEMENT PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

SUBJECTIVE DATA
 Clients statement about reason of admission(C/C):Fall
down injury of 03 weeks duration
 Significant other`s statement about reason of
admission(HPI):HPI=This is a 15 years old male
patient who presented with Fall down injury of 03
weeks duration.associated to this he has redness on his
ankle,swelling and fevere and aching pain on his
ankle which aggravated with mobility and relieved by
rest.otherwise
 he has no headache
 He has no vomiting
 He has no nausea and etc
May 9,2023 BY SURGICAL NURSING STUDENTS
CONT…

Currently she has no palpitation or heat

intolerance.
 No history of drug intake
 No history of fever, chills or neck pain
 No family history of similar illness
 No history of head & neck radiation therapy
 No self/family history of DM, HTN or asthma

May 9,2023 BY SURGICAL NURSING STUDENTS

SUBJECTIVE DATA CONT…
 He has fair perceived health rating
 Substance use: He doesn`t use substances like :-
Alcohol, Khat, tobacco
 Current medication: He was know on
 Ceftraxone 1gm IV BID
 PCM 500mg PO QID
 Metronidazole 350mg IV TID

May 9,2023 BY SURGICAL NURSING STUDENTS

 OBJECTIVE DATA

Vital signs on adimission

Temperature: 37.7◦C
Pulse rate:96 beat per minute,
Respiratory rate: 22 breath per minute,
Blood pressure : 112/69mmHg
Oxygen saturation 95%

May 9,2023 BY SURGICAL NURSING STUDENTS

2,NUTRITION METABOLISM
PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

SUBJECTIVE DATA

No Any change in food/fluid intake because of

illness
 Food taking pattern: He eat break fast, lunch
and dinner.
No history of loss of appetite.
No history of difficulty in chewing.

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data cont…
No history of difficulty in swallowing
No history of Sore tongue.
No history of nausea.
No history of vomiting
No history of abdominal pain .
He was not use of antacid now.

May 9,2023 BY SURGICAL NURSING STUDENTS

SUBJECTIVE DATA CONT…
 No itching Skin condition.
nail condition : no clubbing or discoloration
Dental condition: no - malformation or
discoloration

May 9,2023 BY SURGICAL NURSING STUDENTS

OBJECTIVE DATA
 Skin color : there is no jaundice, pallor,
cyanosis, erythema
 Lesion: there is no petechia, postule, vesicle,
 Texture : Smooth
 Temperature: warm
 Moisture: dry

May 9,2023 BY SURGICAL NURSING STUDENTS

Objective data cont…
 Any visible wound: yes
Type of wound : incisional wound
Location wound: On his right ankle
Discharge: no discharge
 Hair : smooth texture, even distribution and no
scalp lesion

May 09,2023 BY SURGICAL NURSING STUDENTS

Objective data cont…
Oral cavity
Mucosa: intact
Color: pink
Moisture: moist
Teeth : no malformation
Tongue: pink
Nail : has flat shape and pink color

May 9,2023 BY SURGICAL NURSING STUDENTS

3. ELIMINATION PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

SUBJECTIVE DATA
 Bowel habits:
Frequency : 2 times per day
Color: no change
Amount : as a usual
Consistency: formed stool
No use of laxatives.
No use of enema.
No history of bowel surgery.

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data cont…
 Bladderhabits
o Frequency: 3 times per day
o Amount : as usual
o Color: amber
o No history of : dysuria, urgency, hesitancy,
incontinency, retention, and urinary catheter.

May 9,2023 BY SURGICAL NURSING STUDENTS

OBJECTIVE DATA
Abdominal examination
 Inspection
 Shape: flat
 Umbilicus: inverted
 Auscultation : not performed
 Percussion:
 Dull sound on liver and spleen and
 Tympanic sound over bowels and
 Dram like sound over bladder
 Palpation : No palpable abdominal mass

May 9,2023 BY SURGICAL NURSING STUDENTS

4. ACTIVITY-EXERSCISE
PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

SUBJECTIVE DATA
He has difficulty with daily living activities of
 Hygiene.
Education
Toileting
Bathing

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data cont…

 Effectof illness on activity of daily activity: due

to effect of this illness, after surgery he was
bedridden for more than 1months.

May 9,2023 BY SURGICAL NURSING STUDENTS

OBJECTIVE DATA
 Level of dependence : He requires minimal intervention
Musculoskeletal:
 Inspection
 Gait: unsteady

Respiratory
 Inspection:
• Chest symmetry: symmetrical
• No Breathing difficulty.
• Intercostal space : even and relaxed
 Palpation:
• He has Tenderness on his right lower leg.

May 9,2023 BY SURGICAL NURSING STUDENTS

cont…
 Auscultation :not performed
 Percussion: resonance sound be heard
Cardiovascular
NO Jugular vein distension

Ascultation
Pulse rate =75bpm

May 9,2023 BY SURGICAL NURSING STUDENTS

5. SLEEP-REST PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data
Usual sleep time: 6-8 hours
Change in sleep time: yes, when he feel pain
doesn`t fell in sleep. Sleep time 2-5 hours
Adequacy : inadequate
What facilitates sleep: absence of pain
What hinders sleep: presence of pain

May 9,2023 BY SURGICAL NURSING STUDENTS

6. Cognitive- sensory perception

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data
Educational status : primary school
He has able to read and write.
Primary language : hadiyisa
No visual problem.
No hearing problem.
No test problem.
No smelling problem
He has problem in sensation on his right lower
leg.

May 9,2023 BY SURGICAL NURSING STUDENTS

cont…
He has atching Pain on his right lower leg
Explain using PQRST:
P:-pain is provoked/ relived during mobility and
rest respectively.
Q : atching pain
R : no radiation of pain
S : moderate pain
T : intermittent
He has ability to make decision.

May 9,2023 BY SURGICAL NURSING STUDENTS

Objective data
He has ability to speak
Level of consciousness 15/15
He were oriented to time ,place and person.

May 9,2023 BY SURGICAL NURSING STUDENTS

cont…
Skin sensation:- superficial :+ve
-deep pressure :+ ve

May 9,2023 BY SURGICAL NURSING STUDENTS

7. SELF PERCEPTION AND
SELF CONCEPT PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data
What do you feel differently about yourself?
He has no feeling other than pain
He has good perception of abilities.
Pain frequently makes his angry, fearful or
anxious.

May 9,2023 BY SURGICAL NURSING STUDENTS

Objective data
Appearance (dressing and hygiene): fair
Speech: pace of conversation : appropriate
Tone of voice : appropriate to situation

May 9,2023 BY SURGICAL NURSING STUDENTS

8. ROLE – RELATIONSHIP
PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

SUBJECTIVE DATA

Work role: student

Social role :good relationship with his family
and society.
Effect of illness on role: inability to go to school

May 9,2023 BY SURGICAL NURSING STUDENTS

cont…
Employment : student
Able to pay: yes , comment : by “matema”
He has no family history of :- DM, HPN,
Asthma, Cancer

May 9,2023 BY SURGICAL NURSING STUDENTS

Objective data
Interaction with family members and significant
others: good
Visitors flow :minimal

May 9,2023 BY SURGICAL NURSING STUDENTS

9. Coping stress and tolerance
pattern

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data
There is big change in his life
Support system : well
Most helpful person: his mother

May 9,2023 BY SURGICAL NURSING STUDENTS

10. SEXUALITY-
REPRODUCTIVE PATTERN

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data

 No history STD

May 9,2023 BY SURGICAL NURSING STUDENTS

11. VALUE – BLIEF

May 9,2023 BY SURGICAL NURSING STUDENTS

Subjective data
Culturalpractice: yes , comment :hadiya
Religious practice: yes , comment : protestant

May 9,2023 BY SURGICAL NURSING STUDENTS

Objective data
Presence of religios article: not
Religious activity: yes

May 9,2023 BY SURGICAL NURSING STUDENTS

 ADITIONAL CLINICAL
INFORMATION
CBC IMAGING
WBC= 10.1X 10*3 /µl X-ray =Unremarkable
RBC= 5.17X 10*6 \µl
Hgb= 14.9 g/dl
Hct = 41.3%
Platelet
count=844X10*3 /µl

May 9,2023 BY SURGICAL NURSING STUDENTS

Summary of subjective Summary of objective
data data
 Pain Vital signs:
Swelling T=36.1◦C
Anxiety PR=118 bpm
RR=22 breath per minute
BP=102/ 92 mmHg
SpO2= 96%
Incisional wound

May 9,2023 BY SURGICAL NURSING STUDENTS

Nursing diagnosis
 Acute pain related to surgical incision site as
evidenced by patient verbalization
 Risk for impaired skin integrity related to open
wound
 Impaired physical mobility related to
related to Trauma AEB by patients
expression
 Anxiety related to Surgical procedure
AEB patients Facial expression

May 9,2023 BY SURGICAL NURSING STUDENTS

Goal
To relive pain
To monitor vital sign
To maintain skin integrity
To relieve anxiety

May 9,2023 BY SURGICAL NURSING STUDENTS

Expected outcome
Pain will be relieved after administration of iv
analgesics with in 15 min
Patient`s extermity will not be amputated
Impairment of skin integrity will be restored to
normal skin integrity Before his discharge.

May 9,2023 BY SURGICAL NURSING STUDENTS

Intervention

Provide wound care daily

administer ordered antibiotics like ceftraxone
1gm Iv BiD
Managing pain with analgesics

May 9,2023 BY SURGICAL NURSING STUDENTS

Implementation
Wound care daily was provided.
Ceftriaxone 1g IV BID was adiministered
Anti pain medication was administered and
patient was advised to use pillow
Tramadol 50 mg IV TiD was adiministered
by staff nurses
Diclofenac 75mg IM BID was adiministered
Metrindazole 500mg IV TID Was
adiministered

May 9,2023 BY SURGICAL NURSING STUDENTS

 Evaluation
Painis relieved with in 15min after
administration of IM anti-pain medications.
Anxiety is relieved after psychological
adivice.

May 9,2023 BY SURGICAL NURSING STUDENTS

THANK YOU !!

May 9,2023 BY SURGICAL NURSING STUDENTS