WEST VISAYAS STATE UNIVERSITY College of Nursing

NURSING CARE PLAN

Name of Patient: ___TL________________________ Age: _58______ Attending Physician:____Dr. L______________________________ Pathologic fracture right hip, closed complete, transverse Ward/Bed Number:__OSW____ Impression/Diagnoses: femoral neck; fracture secondary to metastatic bone CA, breast mass stage IV Nursing Interventions Independent Note skin color, texture and turgor on site. Determine degree/depth of injury/damage to integumentary system (i.e., involves dermis, epidermis or underlying tissues) Inspect skin on a daily basis, describing wound characteristics and changes observed. Rationale (Scientific Basis) Evaluation

Clustered Cues 11/11/10; am 8:00

Gakatol sa may dressing gid (referring to the wound dressing on her right breast) as verbalized by TL. Disruption skin surface of

Rationale Objectives of Care/ (Scientific Basis ) Outcome Criteria Impaired skin Altered dermis The client will be able integrity related to and/or epidermis. to be free of infection lesions on breast. as evidenced by Breast cancer, in its temperature within advanced stage, normal range of 36.1 oc may erupt on skin -37.5 oc and no swelling as an ulceration. and redness on around the wound. by Nov. 13,2010 12:00 pm.

Nursing Diagnosis

11/12/10; 12:00pm - To assess for existing Goal met. infection. The client was free of infection as To document status or to evidenced by provide visual baseline temperature of o for future comparisons. 36.5 c and no swelling and redness on To monitor progress of insertion site. wound healing.

Wash hands before contact with Washing between patient and between procedures with procedures reduces the patient. risk of transmitting pathogens from one area of the body to another. Keep the area clean/dry. Dress wounds aseptically stimulate circulation. To avoid entry of pathogens. and To assist bodys natural process of repair.

Use appropriate barrier dressings, To protect the wound wound coverings,drainage and/or surrounding appliances and skin-protective tissues. agents for open/draining wounds. Limit/avoid use of plastic material and remove wet/wrinkled linens promptly. Moisture potentiates skin breakdown.

Review importance of skin and The integumentary measures to maintain proper skin system is the largest functioning. multifunctional organ of the body. Discuss importance of early To enhance detection of skin changes and/or understanding and complications. cooperation Assess nutritional status, including Patients with poor weight, history of weight loss and nutritional status may be serum albumin. unable to muster a cellular immune response to pathogens therefore more susceptible to infections. Teach patient signs and symptoms of infection and when to report these. Teach patient to comply with Most antibiotics work if antibiotic therapy as required. constant blood level is maintained and to reduce risk of developing resistant strains. Collaborative Monitor white blood count. Very low WBC indicates severe risk for infection because of lack of sufficient WBCs to fight pathogens. Place patient in protective isolation if To minimize risk of patient is very high risk. infection Administer antimicrobial drugs as For ordered. prevention/prophylactic purposes. Encourage adequate nutrition and Hydrated skin is less hydration. prone to breakdown.

Reference: Doenges, et. al., (2008). Nurses Pocket Guide p.619-624 Sommers, et. al., (2007). Diseases and Disorders, A Nursing Therapeutic Manual. p. 149.

Students Name:_______________________________ Clinical Instructor: _____________________________