#1 Nursing dx: Impaired tissue integrity related to infection (cellulitis) as evidenced by swelling, pain, warmth and tenderness of

affected area
Expected outcome: Patients tissues/skin will return to normal structure and function with no pain, swelling or redness
.
Nursing Interventions
Patient Responses to interventions
1. Assess wound/surgical incision and surrounding skin and
R leg: Hematomas around incision sites; multiple steristrips to lower
drainage (CMS assessment). Take VS (temperature)
leg incisions; C: skin warm, dry, no erythema, pulses palpable, cap
refill brisk; M: foot strength good, full ROM, mild pain on dorsiflexion of
ankle; S: constant mild-mod pain, paresthesias of toes (unrelated),
able to recognize dull sensation
2. Administer antibiotics as ordered
Antibiotics ordered: Zosyn & Vancomycin; pt tolerated w/ no adverse
reaction to IV meds; IV site intact and patent
3. Positioning: Pt to keep leg elevated at all times; toes above
the nose

Pt tolerated elevation throughout the day, no complaints about

position

4. Discharge instructions: Teach patient importance of

Pt verbalized understanding of teaching, continued to review his copy
elevation & compression, taking all antibiotic meds, S&S of
of discharge instructions after I was finished
infection and to notify physician, f/u appointment w/ MD in 1
week
Evaluation of whether outcome(s) are met:
Pt still with mild-mod pain and some swelling. Pain controlled w/ pain meds. Hematomas still present but with continued interventions of
elevation and compression at home, outcomes can be fulfilled.

#2 Nursing dx: Risk for falls related to decreased lower extremity strength and pain
Expected Outcome: Pt will not sustain a fall during their stay
Nursing Interventions
1. Assess pain, ability to walk, environment for factors known
to increase risk for falls

Patient Responses to interventions

Pt oriented to room, no obstructions on the path to the bathroom; pt
able to ambulate 50 feet w/ standby assist, mild pain (2)

2. Place items used by the pt within easy reach, bed in lowest

position

Pts personal items, over bed table, call light, phone within reach

3. Pain control w/ analgesics; administer pain meds as

ordered

Pt was given PRN percocet, currently has mild pain (2), able to
ambulate to bathroom for shower

4. Teach pt importance of pushing the call light when in need

of assistance out of bed

Although AOx4 continued encouragement to push call light for

assistance out of bed for safety, pt verbalizes and demonstrates
understanding (by pushing call light when need to get out of bed)

Evaluation of whether outcome(s) are met:

Yes, pt did not sustain a fall while in hospital. Pt understood safety precautions were in place and cooperated with staff to ensure his
safety