Nursing Care Plan: Ha Noi Medical University
Nursing Care Plan: Ha Noi Medical University
ALLERGIES : no allergies
Pain and swelling of the deltoid muscle (in the left arm)
Present history:
Before admission 10 day, he started to high fever, pain and swelling deltoid muscle (in the
left arm). He came to hospital examination, the result of CT scan he has 2 abscess next to
abdominal aorta and he is admitted Bach Mai Hospital on August 17,2018.
Pulse: 100bpm
BP:130/60 mmHg
RR: 20/bpm
He is aleart, Glasgow :14 point
Medical history:
a, patient history:
b, family history:
Focus assessment:
1. Admission condition:(17/8/2018)
Drowsiness, Glasgow: 15
BP:130/60mmHg
RR:20 pbm
Temperature:38oC
2. Current assessments:(22/8/2018)
- General condition:
- Respiratory system:
- Cardiovacular system:
Patient was injected transmission line in the right hand ( 2ndday), the
needle is clean and unobstructed
- Gastrointestinal system:
No vomiting.
- Genitourinary system:
Total amount urine: 2350ml/day
- Musculoskeletal system:
Total:2360ml/day
Intravenous Therapy
Antibiotic powder
Status stable
Capillary blood glucose
Insulin 2 2 2 2 2 2 2 2
(unit/hours)
Laboratory test
Monocytes % 0 – 8% 5.6
Eosinophils % 0 – 8% 0.3
Basophils % 0 – 1% 0.0
Neutrophils # 1.8 – 7.5G/l 8.0
Lymphocytes # 1.0 – 4.5G/l 0.8
Monocytes # 0 – 0.8G/l 0,5
Eosinophils # 0 – 0.8G/l 0,0
Basophils # 0 – 0.1G/l 0,0
RBC 4.5-5.9 T/l 3.23
Prothombin S 13
PT % 70 – 140 % 77
PT-INR 1.19
APTT s 31.2
Fibrinogen 2 – 4g/l 6.67 increased -> can cause
embolus
Von-Kaulla >60 minute >60
method
D-Dimer <0.48 mg/l FEU 4.476
Immune:
Urine test
SG 1.003-1.030 1.022
PH 5,5-6,5 6.5
-ultrasound:
-CT scan:
abscess next to abdominal aorta lower part of the renal artery, atherosclerosis and
calcified aortic system of pelvic, abscess of right lumbar-pelvic muscle, multifocal
lesions liver parenchyma, kidneys and lungs, large liver.
NURSING PROCESS
-Patient has surgical incision abscess in the left arm , 5cm, 3 rdday and the sutures is
dry, the would is red, swollen, hotter than other hand, pain
1. Assess client for a possible source of 1. The most common causes of sepsis
infection: open wounds, cellulitis, drain, are respiratory tract. Other causes of
hospital inviroment,IV hospital-acquired sepsis are the use of
intravascular devices.
2.check vital sign 3hours 1time, special
temperature, note temperature trends 2. Fever 38.5°C-40°C is the result of
and observe for shaking chills and endotoxin effect on the hypothalamus
profuse diaphoresis and pyrogen-released endorphins.
Hypothermia lower than 36°C is a grave
sign reflecting advancing shock state,
decreased tissue perfusion, and failure of
the body’s ability to mount a febrile
response. Chills often precede
temperature spikes in the presence of
generalized infection.
3. Teach proper hand washing using
3. Hand washing and hand hygiene
antibacterial soap before and after each
care activity lessen the risk of cross-contamination.
Note: Methicillin-resistant
Staphylococcus aureus (MRSA) is most
commonly transmitted bacteria via direct
contact with health care workers who
unable to wash hands between client
contacts.
4. Maintain sterile technique when
changing dressings, and providing site 4. Medical asepsis inhibits the
care, such as an invasive line introduction of bacteria and reduces the
risk of nosocomial infection.
5. Investigate reports of pain out of
proportion to visible signs. 5. Pressure-like pain over an area of
cellulitis may indicate developing of
necrotizing fasciitis due to abscesses
6. Inspect wounds and sites of invasive necessitating prompt intervention
devices daily, paying particular attention
6. Clinical signs, such as local
to parenteral nutrition lines. Document
inflammation or phlebitis, may provide
signs of local inflammation and infection
type of primary infecting organism (s), as
and changes in character wound
well as early identification of secondary
drainage, or urine.
infections.
7. Encourage or provide frequent position
changes, deep breathing, and coughing
exercises 7. Good pulmonary toilet may reduce
respiratory compromise.
8. Wear gloves and gowns when caring
for open wounds or anticipating direct 8. Prevents spread of infection and cross
contact with secretions or excretions. contamination.
Desired Outcomes
-Body temperature elevated above the normal range, patient has been fever
before surgery (max temperature:40oC)
Desired Outcomes
3. Note dependent and general edema. 3. May indicate heart failure, renal or
vascular impairment
4. Evaluate client reports or evidence of
extreme fatigue, intolerance for activity, 4. To assess for signs of poor ventricular
sudden or progressive weight gain, function or impending cardiac failure.
swelling of extremities, and progressive
shortness of breath.
Desired Outcomes
Desired outcomes
Patient has a blood glucose reading of less than 180 mg/dL (<10 mmol/l); fasting
blood glucose levels of less than <140 mg/dL(< 7,5 mmol/l); hemoglobin A1C level
<7%.
- Cognitive limitation
1. Review disease process and future 1. Discussing the disease and clinical
expectations. expectations provides a knowledge base
from which client can make informed
choices.
2. Review individual risk factors, mode of 2. Awareness of means of infection
transmission, and portal of entry of transmission provides an opportunity to
infections. plan for and institute preventive
measures.
3. Discuss need for a good nutritional 3. Good nutrition is necessary for optimal
intake or balanced diet. healing, immune system enhancement,
and general well-being.
Desired Outcomes
Client will correctly perform necessary procedures and explain the rationale
for the actions.
Medicine
Name of drug Dose and route Effects of drugs Side effects of drugs
administration
Meronem 1g 3 vial-divided into 3 -treatment of infections: -digestive disorders
times
Septicemia; Meningitis; -seizures, convulsions
Intravenous Skin and skin structure
infusion: 1vial + infections; -pseudomembranous
100ml NaCl 0.9% Gynecological colitis
infections; Infections in
30 ml/h -allergy
the abdomen; Urinary
tract infections;
22:30 6:00 14:00
Pneumonia and
hospital pneumonia
Selemycin 5 vial
250mg/2ml
Intravenous
infusion + 100ml
NaCl 0.9%
100ml/h ; 22h
-the appearance of a
potassium chloride
tablet in your stool.
-Skin Rash
-Anorexia