Does my care plan look okay ? what do you all think? thanks
“ I do not feel like eating”
Solu-Cortef 100 mg IV Q8hr
Wound L. Foot
Recent hx of UTI
Albumin 9/30/08 2.5 L
Unwillingness to eat
Wbc 9/30 8.4 and 10/02 10.7 normal
Hgb 9/30 11.3 L 10/02 9.7 L
Risk for Infection R/T inadequate secondary defenses, immunosuppression, invasive procedures, and malnutrition.
Client will remain free of infection, as evidenced by normal WBC count, temp < 100 F, and absence of purulent drainage from incisions. Or
1. Client will show no signs and symptoms of infection by discharge?
Note ( cannot teach pt) does not recall information
1. Assess for presence, existence of, and history of risk factors of infection.
2. Monitor white blood count (WBC)
3. Observed/Monitor for signs and symptoms of infection.
4. Assess for nutritional status.
5. Assess immunization status.
6. Stress proper hand washing technique by all caregivers between therapies.
7. Encourage deep breathing, coughing, and turning q 2hr.
8. Provide regular catheter/perineal care and proper foley care daily.
9. Obtain appropriate tissue/fluid specimens for observation and culture/sensitivities testing.
10. Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or cold.
11. Teach patient and caregiver the signs and symptoms of infection, and when to report to physician
12. Review individual nutritional needs, appropriate exercise program, and need for rest.
1. Assess clt at 1530 am. and clt has a Foley catheter present, wound on the L. heel, PICC RAC and Hx of UTI as a risk factor.
2. Monitor WBC count, labs within normal parameters 9/30 (8.4) and 10/02 (10.7).
3. No signs and symptoms (redness, swelling, purulent drainage) at PICC, and Foley clear yellow urine w/o visible sediment and Temp of 98.1 F
4. Albumin level of 2.5 L and unwillingness to eat, pt states “I do not feel like eating”. and < 25% food eaten. Enjoys strawberry ice cream and hot chocolate, but drinks Ensure chocolate.
5. No records of a pneumonax vaccine given. MD placed an ordered and SN administered it.
6. Washed hands before and after pt. contact between therapies. Staff is aware of proper hand washing technique.
7. Taught patient to deep breath, cough and turn q hr, pt needs to be reminded.
8. Provided a total sponge bath on 10/02 at 1000, secured the foley catheter with tape and reminded pt not to pull on catheter, and cleaned the skin around the catheter and washed my hands before and after catheter care.
9. Obtain a Mersa swap at 1700 and results pending
10. Taught son preventive hygiene practices/ methods by return demonstration and to gown up, wear a mask and glove if they have infection or cold.
11. Unable to teach patient the signs and symptoms of infection, pt has short term memory loss, taught patient’s son the signs and symptoms of infection( fever >100 F, foul smelly urine, confusion, redness, purulent drainage at the wound)
12. Advice the nurse the best way to treat this patient is to be placed on routine care, provide enough rest and at sleep use BIPAP 35 %, and provided active and passive ROM. Unable to let patient get out of bed due to high risk of injury.
We do not have to do rationales.