University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2019
Views:

371

Pages:

2
Author:

Prince Sampson

Nursing Care Plan Patient’s Initials: S.O Assessment Data S: patient’s R leg was slightly red and very warm to the touch. Pt says, “my leg hurts” and would yell each time it was touched. O: Was admitted for R leg cellulitis. They came from a group home. The R knee is contracted with no movement available. Pillow between R foot and L thigh. Vitals: AM T: 37.4 P: 100 bpm 02: 94% R: 18 BP: 119/72 Pt is verbal, A+Ox2, disoriented to time and season. Pt is complete care and inc. x2 person lift. Medical Diagnosis: Cellulitis Nursing Interventions and Nursing Diagnosis and Related Goals Rationale ineffective peripheral tissue Interventions STG: perfusion r/t inflammatory process 1. Patient will draw a line damaging skin and underlying tissue, around the edge of secondary to cellulitis. reddened area to track for proregression or regression. 2. Patient will elevate legs STG: patient will draw lines around reddened boarders by the end of during rest periods shift. 3. Use moisturizing lotions regularly. LTG: patient will not develop any further signs of skin breakdown. Rational: tracking the progression of the reddened area will provide information on further treatment needs. Rest periods are encouraged for legs to be elevated. Changing wound dressing weekly promotes quicker healing. Interventions LTG: 1. Keep the area clean and use cream to prevent any tearing from dry or brittle skin 2. Inspect skin and affected Evaluation Met: Patient used permeant marker and drew a line on the boarder of the reddened area. Pt had L leg slightly elevated with a pillow. Nurse assisted with applying cream to the leg daily. Met: Nurse fully assisted bed bath that includes cleansing of the area of infection along with assessing the skin daily. Pt was prescribed antibiotics daily. areas daily 3. Will be prescribed antibiotics to control infection. Rational: Assessing the skin will prevent further progression of infection. Keeping the skin clean and dry reduces the number of bacteria on skin reduces moisture.