Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

No subjective information

Objective

History of diabetes

Hyperglycemia on admission to hospital because does not take at home medications

Scrotal debridement and closure

Disease: cancer, necrotizing fasciitis of the scrotum

Location of wound and possible increase to pathogens

Problem

Risk for infection

Long Term:

1.        Client will remain free from symptoms of infection by the time of discharge.

2.        Client will state the symptoms of infection of which to be aware by the time of discharge.

1.        Observe and report signs of infection such as warmness, redness, discharge, or increased body temperature because careful surveillance of infection should be monitored and increased body temperature of unknown origin is the most common sign of infection (Ackley & Ladwig, 2008, p 495).

2.        Teach the client to also recognize these signs as symptoms (redness, warmness, swelling, discharge, and increased body temperature) because once discharged, the client needs to know when to report back to the doctor for possible infection (Ackley & Ladwig, 2008, p 495).

3.        Note and report laboratory values such as WBC count and cultures because the WBC count and neutrophils are better diagnostic tests for adults for signs of infection (Ackley & Ladwig, 2008, p 496).

Goal still in progress- observed for signs and symptoms of infection.  No warmness, redness, discharge, or increased body temperature noted on assessment.

Goal not met- patient was not told the signs and symptoms of infection to look for at home once discharged.

Patient to be discharged [date] and will reassessed each shift and before patient is discharged home to make sure no infection has been noted before discharge.

Discharge team at Jewish hospital will teach signs and symptoms to look for once discharged home. Will check and assess patient’s knowledge just before time of discharge from hospital.

Risk factors: impaired healing, disease, tissue destruction, and scrotal debridement and closure

Short Term:

1.        Client will demonstrate appropriate care of infection prone area by the end of the teaching session.

2.        Client will demonstrate appropriate hygiene measures such as hand washing and perineal care by the end of the teaching session.

1.        Use appropriate hand hygiene such as by washing hands thoroughly with soap and water or using an alcohol-based hand rub because infection control precaution is required to prevent infection by use of particular attention to hand hygiene and universal precautions (Ackley & Ladwig, 2008, p 496).

2.        Carefully wash and pat dry skin including all skin folds to clean area thoroughly and apply topical bacitracin ointment because appropriate skin care, using avoidance measures, and topical medications can manage chronic skin conditions in most clients (Ackley & Ladwig, 2008, p 496).

3.        Teach client to demonstrate these skills also so that the client can perform these skills once discharged (Ackley & Ladwig, 2008, p 496).

Goal not met- patient was not taught how to clean site to prevent infection on this shift.

Goal in progress- patient demonstrated appropriate hand hygiene with student nurse after urinating.

Patient will be taught by the discharge team at Jewish Hospital and will demonstrate how to appropriately care for site to prevent infection. Will check and assess patient’s knowledge just before time of discharge from hospital.

Patient will be taught how to appropriately care for incision site to prevent infection by the discharge team at Jewish Hospital before the time of discharge.  Will continue to assess hand hygiene each shift and before discharge.