PASCO-HERNANDO State COLLEGE

PRACTICAL NURSING PROGRAM

PRN002 Sections 7902/7904 FUNDS II
Student Name: Cassie Reimel_________________
Client Initials: P.S.__ Room No.: _ICU
Medical Diagnosis: (Prioritize List) _Necrotizing fasciitis, edema, COPD, Sepsis, MRSA, severe osteoarthritis
___________________________
___________________________________________________________________________________
Subjective &
Objective Data

Subjective:
-No known drug
allergies (NKDA)
-Shortness of
breath
-No hx of
smoking,
alcohol or drug
use.
-Pain
-Depressed
Objective:
Height: 410
Weight:
308lbs.
Pain: 9/10 in
LLE
4+ edema
noted

Nursing
Diagnosis with
Evidence (Nsg
Dx: related to)
Risk for
infection r/t tx
of skin infection
as evidence by
necrotizing
fasciitis.
Ineffective
breathing
pattern r/t
administration
of general
aesthetics as
evidence by
intubation.
Impaired oral
mucous
membrane r/t
NPO status and

Goal/Outco
me
(specific,
measurable
Resolution
of the s/s of
infection.

Pt will
maintain
desired
respiratory
status and
normal
ABGs.

Implementation/Intervention
s

Maintain asepsis for each

dressing change and during
wound care, and IV access
management.
Monitor I&O and daily
weight.
Assess for infection.
Assess ABGs.
Monitor for peak airway
pressures and airway
clearance.

Maintains
intact, pink
and moist
oral mucous
membranes

Assess the lungs for the

presence of normal or
adventitious breath sounds.

Rationale &
Source Citation
(w/ source,
page number)
Use of aseptic
technique
decreases
chances of
transmitting
pathogens to
the pt. Gulanick
and Myers
(2014, p.108).
Fluids promote
diluted urine
and emptying
of bladder,
reducing stasis
urine, reduces
risk for bladder
infection or UTI
(Gulanick,
2014, pg.108).

Evaluation of
Outcomes

Decreased WBC
within one
week, prior to
discharge.
Pt will breathe
easily while
intubated with
mechanical
ventilator, while
in ICU.
Absence of
inflammation of
oral mucous
membranes
while
mechanical
ventilator used.

PASCO-HERNANDO State COLLEGE

PRACTICAL NURSING PROGRAM
PRN002 Sections 7902/7904 FUNDS II
Student Name: Cassie Reimel_________________
Client Initials: P.S.__ Room No.: _ICU
Medical Diagnosis: (Prioritize List) _Necrotizing fasciitis, edema, COPD, Sepsis, MRSA, severe osteoarthritis
___________________________
___________________________________________________________________________________
Past medical
Hx:
-hypertension
-cervical cancer
-morbid obesity
-osteoarthritis
-fatigue
-weakness
-hysterectomy
-hernia repair
Labs:
C-react
protein: 10.5 H
K+: 3.2 L
BUN: 28 H
Ca: 8.0 L
Total protein:
6.1 L
Albumin: 1.0 L
Globulin: 5.1 H
A/G ration: 0.2
L
Magnesium:

mechanical
ventilator as
evidence by
intubation.

that are free

of ulceration
and debris

Inspect oral cavity at least

once daily and note any
discoloration, lesions,
edema, bleeding, exudate,
or dryness.
Provide suctioning as
needed.
Provide oral care with soft
toothbrush or foam sticks.
Chlorhexidine based rinses
may be incorporated.

The presence of
pts wounds,
indwelling
catheter,
wound vac,
feeding tube
and IV sites, all
represent a
break in the
bodys normal
first line of
defense
(Gulanick,
2014, pg.107).
Signs of
respiratory
compromise
include
decreasing
PaO2 and
increasing
PaCO2

PASCO-HERNANDO State COLLEGE

PRACTICAL NURSING PROGRAM
PRN002 Sections 7902/7904 FUNDS II
Student Name: Cassie Reimel_________________
Client Initials: P.S.__ Room No.: _ICU
Medical Diagnosis: (Prioritize List) _Necrotizing fasciitis, edema, COPD, Sepsis, MRSA, severe osteoarthritis
___________________________
___________________________________________________________________________________
1.7 L
ABG:
compensated
metabolic
acidosis
PCO2: 31.0 L
PO2: 120.0 H
HCO3: 16.7 L
BE(VT)#: -7.7
L
THB: 7.2 L
TCO2: 17.7 L
H-ADO2 #:
55.0 H
WBC: 21.4 H
RBC: 3.08 L
Hemoglobin:
9.5 L
Hematocrit:
29 L
Neutrophil %:
84 H
Lymphocyte
%: 6 L

(Gulanick,
2014, pg.467).
Increases in
peak airway
pressures and
airway
resistance
parameters
signals the
accumulation of
secretions or
fluid and the
potential for
ineffective
ventilation
(Gulanick,
2014, pg.467).
Diminished lung
sounds or the
presence of
adventitious
sounds may

PASCO-HERNANDO State COLLEGE

PRACTICAL NURSING PROGRAM
PRN002 Sections 7902/7904 FUNDS II
Student Name: Cassie Reimel_________________
Client Initials: P.S.__ Room No.: _ICU
Medical Diagnosis: (Prioritize List) _Necrotizing fasciitis, edema, COPD, Sepsis, MRSA, severe osteoarthritis
___________________________
___________________________________________________________________________________
SEDrate: 107
H

indicate an
obstructed
airway and the
need for
suctioning
(Gulanick,
2014, pg.467)
Mouth care
prevents
buildup of oral
plaque and
bacteria. Pts
with oxygen
therapy require
additional care
(Gulanick,
2014, pg.142).
Suctioning
prevents
accumulation of
secretion that
can be

PASCO-HERNANDO State COLLEGE

PRACTICAL NURSING PROGRAM
PRN002 Sections 7902/7904 FUNDS II
Student Name: Cassie Reimel_________________
Client Initials: P.S.__ Room No.: _ICU
Medical Diagnosis: (Prioritize List) _Necrotizing fasciitis, edema, COPD, Sepsis, MRSA, severe osteoarthritis
___________________________
___________________________________________________________________________________
aspirated
Gulanick, 2014,
pg.466).
Oral care
reduces
colonization of
the oropharynx
with respiratory
pathogens that
can be
aspirated into
lungs (Gulanick,
2014, pg.466).

PASCO-HERNANDO State COLLEGE

PRACTICAL NURSING PROGRAM
PRN002 Sections 7902/7904 FUNDS II
Student Name: Cassie Reimel_________________
Client Initials: P.S.__ Room No.: _ICU
Medical Diagnosis: (Prioritize List) _Necrotizing fasciitis, edema, COPD, Sepsis, MRSA, severe osteoarthritis
___________________________
___________________________________________________________________________________

PASCO-HERNANDO State COLLEGE

PRACTICAL NURSING PROGRAM
PRN002 Sections 7902/7904 FUNDS II
Student Name: Cassie Reimel_________________
Client Initials: P.S.__ Room No.: _ICU
Medical Diagnosis: (Prioritize List) _Necrotizing fasciitis, edema, COPD, Sepsis, MRSA, severe osteoarthritis
___________________________
___________________________________________________________________________________