Gangrene Nursing Care Plan

Nursing Care Plan Admitting/current medical diagnosis & definition: Student 73 y/o Female with Gangrene from s/p surgical site infection of elective partial foot amputation due to PVD. Gangrene is a dangerous and potentially fatal condition that happens when the blood flow Date(s): 3/8/2022 to a large area of tissue is cut off. This causes the tissue to break down and die. (Marks, H 2021). Instructor: Assessment Diagnosis Plan Implementation Evaluation Include only the supporting data cluster related to each diagnosis Provide one (1) PRIORITIZED Nursing Diagnosis Provide 1 short- & 1 long-term goal relevant to the nursing diagnosis Provide 3 appropriate interventions w/ rationales for short-term goal and 3 appropriate interventions w/ rationales for long-term goal. Evaluate outcomes & evaluative criteria for both short- & long-term goal. Subjective data: Impaired skin integrity related to necrotic tissue as evidenced by eschar. (Nursestudy.net, 2022) Short term goal: Short term goals: Short term goal: 1a. Nurse will change dress wounds daily to keep skin dry and intact. pt. verbalizes the importance of turning schedules to minimize risk of pressure sores. 1b. Nurse will encourage proper hydration to avoid further skin breakdown and from developing new ones. Long term goal: Pt complains of pain of 4 on a scale of 010. Objective data: Vitals: RR- 14bpm HR- 65 BPM BP- 110/75 mmHg Sats- 98% R.A Pt appears comfortable with no distress noted. Wound dressing changed. Wound measurement is 5x5 and eschar throughout. Moderate odor due to necrotic tissue. After 4 hours of nursing intervention, pt. will be able to verbalize the importance of patient turning to minimize the risk of pressure sores. Long term goal: Pt will be able to experience optimal wound healing and avoid the spread of infection to the rest of the skin to preserve its integrity. 1c. Nurse will have a set turning schedule to prevent pressure sores. Long term goals: 1d. Assess the skin for its integrity, color, moisture, and texture for any further deterioration. 1e. nurse will teach the client about skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. 1f. nurse will teach patient and family aseptic methods Pt and family verbalize the importance of aseptic method of wound care to reduce the spread of infection. Such as hand washing with wound care. (Nursestudy.net, 2022) Pertinent Physical Examination findings - Pale and thin Moderate odor from the wound site Contributing Factors Pertinent History Priority Nursing Diagnosis - Hx of ETOH HTN FTT Pseudomonas UTI Osteoporosis Severe Thrombocytosis Debility Latent TB Impaired skin integrity related to necrotic tissue as evidenced by eschar. Nursing Interventions 1a. Nurse will change dress wounds daily to keep skin dry and intact. 1b. Nurse will encourage proper hydration to avoid further skin breakdown and from developing new ones. 1c. Nurse will have a set turning schedule to prevent pressure sores. 1d. Assess the skin for its integrity, color, moisture, and texture for any further deterioration. 1e. nurse will teach the client about skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. 1f. nurse will teach patient and family aseptic methods Such as hand washing with wound care. Medications for this Condition Drug name, route, dose, actions, and reason patient is taking this drug. Rocephin 1000 mg IV Q24 hr. is a broadspectrum antibiotic that works against gram + and gram – bacteria. Tylenol oral 1 tablet of 500 mg Q6 PRN for pain Levofloxacin 500 mg IV Q24 hour is a quinolone antibiotic for UTI. Pt’s Initials: MB Age: 73 y/o Medical Diagnosis: Gangrene of the foot Pathophysiology Gangrene is a dangerous and potentially fatal condition that happens when the blood flow to a large area of tissue is cut off that causes the tissue to break down and die. (Marks, Hedy December p9 2021). Recent Laboratory/Diagnostic Data Hepatic function panel such as AST/SGOT, Albumin to see how Patient’s liver functions are especially when patients are on high dose antibiotics. CBC with Differential to monitor for infection Anticipated Patient Teaching Psychosocial / Spiritual issues /discharge needs Patient is in denial and refuses to get amputation from knee below. Pt thinks that her wound will heal and DR who had previously performed partial amputation of forefoot will be able to cure this gangrene. - Social services are involved to help patient cope with the disease process. OT and PT are also involved in the care for teaching patient with balance, transfer technique, mobility with medical devices such as wheelchair and walker. Dietitian is involved to encourage pt. to consume well balanced meal and to increase calorie consumption to meet patients’ nutritional needs for proper wound healing Date: Name: 3/06/2022 Course: Instructor: Medication Lists Route, Dose/Rate, Time/ Frequency List minimum of five (5) patient medications. Medication/IV Fluid Generic & Trade Name 1. Ceftriaxone 1000mg IV Q24. (Rocephin) Class of Drug/ Why Ordered Cephalosporins and is ordered for skin and soft tissue bacteria since it is a broad-spectrum antibiotic. Mechanism of Action Ceftriaxone works by inhibiting the mucopeptide synthesis in the bacterial cell wall. The beta-lactam moiety of ceftriaxone binds to carboxypeptidases, endopeptidases, and transpeptidases in the bacterial cytoplasmic membrane. These enzymes are involved in cell-wall synthesis and cell division. Binding of ceftriaxone to these enzymes causes the enzyme to lose activity; therefore, the bacteria produce defective cell walls, causing cell death. 2-3 Contraindications Hemolytic anemia, Neonates, Renal impairments 2-3 Most Common Major Side Effects rash, and abnormal liver function test. Mild diarrhea. Nursing Considerations for Safe Administration Nurse should assess for any severe GI problems such as vomiting, nausea and diarrhea monitor IV site for pain, swelling and irritation. (DrugBank Online, 2022) Levofloxacin (Levaquin) 5oomg IV Q24 Quinolone antibiotics and is ordered for UTI directly inhibits bacterial DNA synthesis. Levoflo xacin promotes Pregnancy, nursing mothers, hypersensitivity Children under 18 years of age. Photosensitivity, headache, nausea, diarrhea. Nurse should monitor toxicity levels. Nurse should assess the IV site for any Acetaminophen (Tylenol) 500 mg of 1 tablet by mouth Q6 as needed. It is an analgesic drug and is ordered for pain management. the breakage of DNA strands by inhibiting DNAgyrase in susceptible organisms, which inhibits the relaxation of supercoiled DNA. (Poddar, V & Sadiq, N (September 22, 2021) It has the ability to inhibit the cyclooxygenase (COX) pathways that lead to alleviation of pain symptoms. (DrugBank Online, 2022) Acute liver failure acute inflammation of the liver due to hepatitis C virus. (WebMD, 2022) tenderness, redness or swelling. Hypersensitivity, rash and itching. Dizziness and trouble breathing. Total ____________ /30 points Nurse should monitor for signs of overdose. Nurse should assess for desired effects of pain/discomfort relief. RN 201 - MEDICAL/SURGICAL I CLINICAL-INTRODUCTION TO MED/SURG CLINICAL