EDISON COLLEGE NURSING PROGRAMS
NURSING CARE PLAN
ASSESSMENT DATA
(Appropriate data to support
nursing diagnosis, include
subjective and objective data)
Subjective:
Patient denies feeling febrile
Patient denies malaise
Patient denies history of MRSA
Objective:
12cm craniotomy surgical
incision on rear left of
cranium, well approximated
wound edges with dried
serosanguinous drainage,
healing by primary intention,
closure with staples,
granulation tissue present,
skin around wound warm
(normal warm) to touch
Patient has a Foley urinary
catheter
Open fracture of right lower
leg, heavily bandaged
(doctors order to not
remove), toenail cap refill of
effected leg <3 seconds, skin
on toes warm (normal warm)
to the touch. Wound vac
treatment on right lower leg,
chamber containing
serosanguinous drainage
WBC: 7.1
Temp: 98.5F
NURSING DIAGNOSIS
(Must include scientific
rationale for the diagnosis,
include references*)
Risk for infection
R/T: surgical incision wound
and open fracture of right
lower leg
Scientific Rationale:
An open fracture carries
significant risk for wound
contamination and
subsequent infection. The
patient who undergoes
surgery will have a
postoperative wound. Any
break in skin integrity must be
monitored for infection.
(Lemone 2011 p.1326)
Pathophysiology:
Infection occurs when an
organism is able to colonize
and multiply within a host. An
infection causing
microorganism must have
virulence, be transmitted
from its reservoir, and gain
entry into the susceptible
host. When the immune
system is alerted that an
invader has entered the body,
cytokines send a message to
phagocytes to attack the
infection. Lymphocytes and
other white blood cells also
begin to attack the
microorganism. The result of
PLANNING
Goals (include realistic short
and long term
client-centered goals)
Short Term/Long Term
Interventions
Short Term:
1. At the end of the shift,
patient will remain free of
signs / symptoms of
infection such as WBC
count of 4,500-
10,000/mm3, temp of < 100
F, and absence of purulent
drainage wounds.
Long Term:
1. At time of discharge,
patient will be free of signs
/ symptoms of infection
such as WBC count of
4,500-10,000/mm3 temp of
< 100 F, and absence of
purulent drainage wounds.
Planned Nursing
Interventions:
1. Throughout shift, nurse will
continue to monitor for
signs and symptoms of
infection, such as elevated
systemic temperature,
reddening of the area
surrounding the wound,
increased temperature of
skin surrounding the
wound, purulent wound
drainage, and elevated
WBC count.
2. Nurse will administer
NURSING
IMPLEMENTATION
(What actually was done, must
include scientific rationale with
references and delegation of
tasks*)
1. Nurse monitored for signs
and symptoms of
infection, such as elevated
systemic temperature,
reddening of the area
surrounding the wound,
increased temperature of
skin surrounding the
wound, purulent wound
drainage, and elevated
WBC count multiple times
throughout shift.
Common assessment
findings of an infected
wound include purulent
discharge, redness,
warmth, fever, & elevated
WBC. (Lemone 2011
pp.78, 288, 294-295)
2. Nurse administered
antibiotics as per
physicians orders.
Antibiotics are
medications used to treat
bacterial infections and
some have activity against
a wide variety of bacteria.
Prophylactic antibiotic
treatment is effective in
the prevention of
postoperative
complications. (Lemone
2011 p. 297)
3. Nurse provided regular
EVALUATION
(Actual outcome of care and
appropriate follow-up actions)
Goals
Implementations
Short Term goals evaluation:
1. At the end of shift, patient
was free of signs /
symptoms of infection.
Temp - 98.7, 98.1. WBC
was not ordered to be
checked again during
nurses shift. Wound
characteristics were: RLL
was only able to see
drainage in wound vac, it
remained serosanguinous.
Toes (distal to injury)
remained pink and not
overly warm. Cranial
incision did not produce
any new drainage and was
either excessively red or
warm. Goal met.
Long Term goal evaluation:
1. If client and nursing staff
continue with these
interventions, in all
likelihood, the patient
should remain free of
signs / symptoms of
infection. Goal on its way
to being met.
Evaluation of interventions:
1. Patient was monitored
throughout shift for s/s of
infection and none were
present. Although no
infection is present,
continue intervention for
this activity often results in a
fever and causes the blood
vessels to enlarge in order to
increase the amount of blood
containing phagocytes and
lymphocytes to the site of
infection. (Lemone 2011 pp.
270-273, 292)
antibiotic drugs, as per
physicians orders
3. Nurse will provide urinary
catheter care & cleansing
at least once per shift.
4. Nurse will observe proper
hand hygiene and aseptic
technique when caring for
wounds.
4. Nurse observed hospital
5. Educate client on the
importance of consuming
adequate amounts of
protein, calories, and fluids
to promote wound healing.
5. Nurse spoke to patient
catheter care with soap
and water once during
shift. *Delegated to female
student nurse.
Catheter care prevents
access and limits bacterial
ascent into, and growth
in, urinary tract. (Doenges
/ Moorhouse / Murr 2010,
p.353)
policies and procedures in
regard to hand hygiene
and aseptic technique
when caring for patients
wounds.
Hand hygiene remains the
single most important
factor in preventing the
spread of infection.
Standard precautions are
essential in protecting the
patient and the nurse
from infection by
preventing cross-
contamination and
exposure to infectious
organisms. (Lemone 2011
pp.250, 302)
regarding the important
role that protein, calories,
and fluids play in the
process of wound healing.
Calories and proteins are
needed to meet metabolic
needs and promote
wound healing. Fluids
prevent dehydration and
promote blood perfusion.
(Doenges / Moorhouse /
Murr 2010, p.679)
early detection. Goal met.
2. Patient was administered
antibiotics as per
physicians orders. No s/s
of infection present. Goal
met. Continue this
intervention.
3. Patient was provided
urinary catheter care once
during shift. It was
delegated to female
nursing students. No s/s of
infection present. Urinary
catheter care is important
in preventing
contamination of the
urinary tract, so continue
this intervention. Goal
met.
4. Adherence to hospital
policy and procedure
regarding hand washing
and aseptic technique
when providing wound
care and/or observation
was heeded. No s/s of
infection present. Goal
met. Continue this
preventative intervention.
5. Nurse educated patient
regarding the importance
of nutrition, especially
protein, calories, and
adequate fluid intake in
the process of healing.
Patient demonstrated
understanding of the
concepts by restating.
Goal met. Discontinue
intervention.