Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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Subjective
Nurse noted in shift change report about the pt’s pressure ulcer.
Objective
Documented pressure ulcer of 2X3
inches, 1 inch in depth, with clear, non-odorous drainage
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Problem
Risk for infection
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Long Term:
Pt will demonstrate appropriate hygienic measures such as hand washing, oral care,
and perineal care by discharge.
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*Teach the importance of appropriate hand hygiene
Rationale: “Meticulous infection control precautions
are required to prevent infection, with particular attention to hand hygiene”
(Ackley & Ladwig, 2008, p. 496).
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ü
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R/T
Stage II pressure ulcer on coccyx
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Short Term:
Pt will remain free from symptoms of infection throughout this shift, by 1900.
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*Observe and report any signs of infection such as redness, warmth, and discharge.
Rationale: “Prospective surveillance study for nosocomial infection on hematology”
(Ackley & Ladwig, 2008, p. 495).
*Use careful sterile technique when there is a loss of skin integrity.
Rationale: “Extensive literature search revealed that sterile gloves should be used
for postoperative wound dressing changes” (Ackley & Ladwig, 2008, p. 497).
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