Nursing Diagnosis for Tonsillitis : Preoperative 1. 2. 3. Swallowing disorders related to inflammatory processes.

Acute pain related to tonsil tissue swelling. Imbalance nutrition less than body requirements related to tonsil tissue swelling.

4. Hipertermi related to the disease process.

5. Anxiety related to discomfort.

Nursing Diagnosis for Tonsillitis : Postoperative 1. 2. 3. Acute pain related to surgical incision, tissue discontinuities. High risk of infection related to invasive procedures. Lack of knowledge about the diet related to less information.

Nursing Diagnosis Impaired Skin integrity Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis). Related Factors: External: Hyperthermia, hypothermia, chemical substance, mechanical factors (e.g. friction, shearing forces, pressure, restraint), physical immobilization, humidity, extremes in age, moisture, radiation, medications Internal: Altered metabolic state, altered nutritional state (e.g. obesity, emaciation), altered circulation, altered sensation, altered pigmentation, skeletal prominence, developmental factors, immunological deficit, alterations in skin turgor (change in elasticity), altered fluid status. Suggested Nursing Outcomes Tissue Integrity: Skin and Mucous Membranes Wound Healing: Primary Intention Wound Healing: Secondary Intention Regains integrity of skin surface Reports any altered sensation or pain at site of skin impairment Demonstrates understanding of plan to heal skin and prevent reinjury Describes measures to protect and heal the skin and to care for any skin lesion Incision Site Care Pressure Ulcer Care Skin Care: Topical Treatments Skin Surveillance Wound Care

Client Outcomes

Suggested Nursing Interventions

Nursing Interventions and Rationales Nursing Interventions Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently . For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors. A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear. Rationales Prior assessment of wound etiology is critical for proper identification of nursing interventions.

Systematic inspection can identify impending problems early.

Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours Evaluate for use of specialty mattresses, beds Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudates Avoid massaging around the site of skin impairment and

To reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed.

over bony prominences. Assess client's nutritional status Massage may lead to deep-tissue trauma Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing Home Care Interventions Client and Family Teaching

Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing Teach client to use a topical treatment that is matched to the client, wound, and setting. If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours Teach client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury

Subjective I do not feel like eating Objective Solu-Cortef 100 mg IV Q8hr RAC PICC Foley Catheter Wound L. Foot Recent hx of UTI Albumin 9/30/08 2.5 L Unwillingness to eat Wbc 9/30 8.4 and 10/02 10.7 normal Hgb 9/30 11.3 L 10/02 9.7 L Risk for Infection R/T inadequate secondary defenses, immunosuppression, invasive procedures, and malnutrition. GOAL: Client will remain free of infection, as evidenced by normal WBC count, temp < 100 F, and absence of purulent drainage from incisions. Or 1. Client will show no signs and symptoms of infection by discharge? Note ( cannot teach pt) does not recall information Assessment 1. Assess for presence, existence of, and history of risk factors of infection. 2. Monitor white blood count (WBC) 3. Observed/Monitor for signs and symptoms of infection. 4. Assess for nutritional status. 5. Assess immunization status. Decrease stressors: 6. Stress proper hand washing technique by all caregivers between therapies. 7. Encourage deep breathing, coughing, and turning q 2hr. 8. Provide regular catheter/perineal care and proper foley care daily. 9. Obtain appropriate tissue/fluid specimens for observation and culture/sensitivities testing. Teaching/counseling/referrals: 10. Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or cold. 11. Teach patient and caregiver the signs and symptoms of infection, and when to report to physician 12. Review individual nutritional needs, appropriate exercise program, and need for rest. Assessment 1. Assess clt at 1530 am. and clt has a Foley catheter present, wound on the L. heel, PICC RAC and Hx of UTI as a risk factor. 2. Monitor WBC count, labs within normal parameters 9/30 (8.4) and 10/02 (10.7). 3. No signs and symptoms (redness, swelling, purulent drainage) at PICC, and Foley clear yellow urine w/o visible sediment and Temp of 98.1 F 4. Albumin level of 2.5 L and unwillingness to eat, pt states I do not feel like eating. and < 25% food eaten. Enjoys strawberry ice cream and hot chocolate, but drinks Ensure chocolate. 5. No records of a pneumonax vaccine given. MD placed an ordered and SN administered it. Decrease stressors: 6. Washed hands before and after pt. contact between therapies. Staff is aware of proper hand washing technique. 7. Taught patient to deep breath, cough and turn q hr, pt needs to be reminded. 8. Provided a total sponge bath on 10/02 at 1000, secured the foley catheter with tape and reminded pt not to pull on catheter, and cleaned the skin around the catheter and washed my hands before and after catheter care. 9. Obtain a Mersa swap at 1700 and results pending Teaching/counseling/referrals: 10. Taught son preventive hygiene practices/ methods by return demonstration and to gown up, wear a mask and glove if

they have infection or cold. 11. Unable to teach patient the signs and symptoms of infection, pt has short term memory loss, taught patients son the signs and symptoms of infection( fever >100 F, foul smelly urine, confusion, redness, purulent drainage at the wound) 12. Advice the nurse the best way to treat this patient is to be placed on routine care, provide enough rest and at sleep use BIPAP 35 %, and provided active and passive ROM. Unable to let patient get out of bed due to high risk of injury.

We do not have to do rationales.

A wound infection happens when germs enter a break in the skin. These germs, called bacteria, attach to tissues causing wounds to stop healing, and other signs and symptoms. Wounds can be punctures (holes), lacerations (tears), incisions (cuts), or burns. Deep ulcers (open sores), large burns, or bite wounds are more likely than other wounds to get infected. Wound infection can also happen in small wounds that were not treated.