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Medical Diagnoses: Impaired skin integrity related to interrupted healing of surgical area, delayed surgical recovery and imbalanced nutrition


1.      Impaired skin integrity related to interrupted healing of surgical area and disability.

·         1 inch unhealed incision draining purulent fluid from site

·         4 4x4’s saturated every 6hrs

·         Cerebral palsy predominantly affecting right side

3.  Acute pain related to previous incision.

·         Pt. rates pain 6 out of 10 on the pain scale before PO pain medication

·         Physician prescribes PO 7.5 Percocet Q4H as needed

·         Pain increases during ambulation and repositioning

2. Delayed Surgical Recovery related to previous right TSA

·         Interrupted healing of surgical area

·         Loss of appetite

·         Difficulty in moving about

·         Fatigue

·         Cerebral palsy predominantly affecting right side

4. Imbalanced nutrition, less than body requirements related to interrupted healing of surgical area and pain

·         Loss of appetite

·         Fatigue

·         Hyperactive bowel sounds

·         Physician ordered pt. be on NPO

Chief Complaint:  A 61 year old white male with purulent drainage from a previous surgical incision site in the right shoulder from a right total shoulder arthroplasty related to an injury.

 

Priority Assessment:  Monitor vitals and pain.  Practice standard precautions to help prevent infection.  Monitor LOC and mobility. Monitor the volume of drainage, bandages and appearance of incision site.  Monitor I’s and O’s. Monitor hematology and blood cultures.

7.

Fatigue related to interrupted healing of surgical area and pain

·         Pt. rates pain 6 out of 10 on the pain scale before PO medication

·         Physician prescribes PO 7.5 Percocet Q4H as needed

·         Pain increases during ambulation and repositioning

5. Activity intolerance related pain and interrupted healing of surgical area and disability

·         Needs assistance with ADL’s

·         Unable to position self comfortably

·         Pain and medication can have side effects that affect LOC

6. Impaired mobility related to acute pain, interrupted healing of surgical area and disability

·         Needs assistance with ADL’s

·         Unable to position self comfortably

·         Pain and medication can have side effects that affect LOC

·         Right arm in sling

8. Risk of infection related to interrupted healing of surgical area

·         1 inch unhealed incision draining purulent fluid from site

·         4 4x4’s saturated every 6hrs

·         Cerebral palsy predominantly affecting right side

·         Physician prescribed 1500 mg of Vancomycin Q12H IV

NANDA Diagnostic Statement: Impaired skin integrity related to interrupted healing of surgical area AEB purulent drainage from previous incision site.

 

Behavioral Outcome / Goal: Pt. will remain free from signs and symptoms of infection by 2/19/20xx.  Pt. will report a decrease in pain from 6 down to 2 on the pain scale by 2/18/xx. Pt. will increase physical mobility safely without injury.  Pt. will have unimpaired skin healing.



Nursing Interventions:

 

1.      Monitor pt. for signs of infection at least daily. Such as hematology and drainage from site.

 

2        Keep pt.’s room temperature and humidity constant.  Room temperature should be kept close to 72 degrees and humidity at a low level unless otherwise ordered.

 

3        Maintain good body hygiene.  Make sure the pt. has at least a sponge bath every day unless skin is too dry.

 

4        Teach the pt. about the principles of good hygiene.                                      

 

5        Reposition pt. at least every 2 hours.  Maintain alignment with pillows and monitor positioning around right shoulder area.  Prevent skin breakdown.

6.   Provide pt. a peaceful and quiet environment for resting and healing._______________________________

Rationale:

 

1.      Infection, through production of toxins, wastes, and so on, increase the probability of tissue damage. (Cox’s Clinical pg: 219)

2.      Keeps skin cool and dry to prevent perspiration. (Cox’s Clinical pg: 219)

 

3.      Practicing good hygiene decreases chance of infection. (Cox’s Clinical pg: 219)

 

4.      Promote self-care and self-management to prevent problem. (Cox’s Clinical pg: 218) 

 

5.      Help stimulate circulation.  Alignment helps prevent pain malpractice and enhances comfort. (Cox’s Clinical pg: 488)

6.      Promotes action and effect of medication by providing decreased stimuli. (Cox’s Clinical pg; 488)

Client Response:

 

1.      Pt. watched closely to his drainage and let the nurse know about his over saturated bandages.

 

2.      Pt.’s room kept at 72 and pt. is comfortable and cool.

 

3.      Pt. didn’t understand the reasoning for a sponge bath everyday but once it was explained to him he was compliant and reported feeling better afterwards.

4.      Pt. understood once taught the importance of hygiene and was compliant and reported feeling better afterwards.

5.      Every 2 hours help pt. shift weight to different positions that does not affect incision site and does not affect the healing process.

6.      Pt. has semi private room but there is not a roommate. Pt. is calm, alert and watching t.v. He is not in distress.

Summarize impressions of client progress toward outcomes / problem resolution: Pt. is stable.  Pt. is experiencing purulent drainage from a previous incision site from a right TSA.  Blood cultures and bone scan came back negative. Physician has scheduled an irrigation and debridement on pt.’s right shoulder. Physician also ordered the pt. to be NPO for surgical purposes.  Physician ordered 1500 mg of Vancomycin Q12H IV.  Pt. wears a sling to position right arm and shoulder correctly.  Placed over the site is 4 4x4’s and island dressing.  Keep dressing clean and dry when saturated. Pt. is voiding on own.  Last BM 2/16/12. Hyperactive bowels with no appetite.  Pt. will be discharged to a long term care facility where a number of antibiotics will be administered daily through IV for 5 to 6 weeks.  Pt. will also need physical therapy.===  


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