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Jason Kucharik

October 30, 2013


M.I. 66y
Clients Surgical Procedure:
Abdomina !ound e"#oration and debridement
Expected Outcomes:

1. $atient remains %ree o% in%ection, e&idenced by an absence o%
#uruent draina'e %rom !ounds
2. $atient &erbay identi(es seection o% %oods and meas that !i
#romote heain'
3. $atient &erbay identi(es desired earnin' outcomes and
demonstrates ase#tic !ound care techni)ue
Objective Data:
1* inch (ssure esion, t!o inches abo&e na&e and 3* (ssure
esion on na&e.
Subjective Data:

$atient states, +I had to come back because it 'ot in%ected and
did not hea #ro#ery.*
Nursing Diagnosis 1:
,isk %or in%ection, reated to sur'ica #rocedure, as e&idenced by
inade)uate de%ense o% skin due to incisions.
Nursing Interventions it! rationale:
1. -e'innin' o% shi%t, monitor %or si'ns o% in%ection .redness,
s!ein', increased #ain, #uruent draina'e %rom incisions/.
Monitor 0-1 counts, check #atient2s tem#erature and &itas
daiy.
An increasing WBC count and fever indicates the bodys eforts
to combat pathogens. Very low WBC count indicates severe risk
for infection. !"#$ %n older patients& infection may be present
without an increased WBC count.
2. Assess nutritiona status, trans%errin' and serum abumin.
'atients with poor nutritional status may be unable to muster a
cellular immune response to pathogens and are therefore more
susceptible to infection. (erum albumin levels intricate the
degree of protein depletion that would efect wound healing. %t
can be also seen in in)ammation. "ransferrin is important for
iron transfer but it typically decreases as serum protein
decreases.
3. 3ncoura'e daiy intake o% #rotein and caorie rich %oods %or
#ro#er !ound heain'. -e%ore dischar'e, assess the #atient2s
%ood #re%erences. $ro&ide !ritten materias istin' %oods hi'h in
#rotein and in caories. 4a&e #atient and %amiy member .care
taker/ &erbay identi%y !hich %oods !i he# #romote heain'.
!ptimal nutritional status supports immune system
responsiveness and promotes wound healing.
Nursing Diagnosis ": 5e(cient kno!ed'e reated to #rior sur'ica
#rocedure, as e&idenced by in%ection and &erbai6in' incorrect
#rocedure o% treatment.
Nursing Interventions it! rationale:
4. 7each the #atient and %amiy member the im#ortance and
techni)ue o% !ashin' hands. 5emonstrate ase#sis %or dressin'
chan'es and !ound care mana'ement. 4a&e #atient and %amiy
member demonstrate #ro#er #rocedure o% ase#sis and !ound
care be%ore dischar'e. 7each them the si'ns o% in%ection
.redness, s!ein', increased #ain, #uruent draina'e %rom
incisions/ and to re#ort these to the #hysician or nurse. $atient
and %amiy member !i both &erbay identi%y si'ns o% in%ection
be%ore dischar'e.
'atients& family members and caregivers can spread infection
from one part of the body to another& as well as pick up surface
pathogens* hand washing reduces these risks. 'atients need to
be able to recogni+e important signs and changes in their
condition so early treatment can be initiated. ,se of aseptic
techni-ue decreases the chances of transmitting or spreading
pathogens to the patient.
5. 7each the #atient and %amiy member !hy it is im#ortant to take
antibiotics as #rescribed and to take the %u course o% antibiotics
e&en i% the incision condition im#ro&es or disa##ears.
.ost antibiotics work best when constant blood level is
maintained from taking the medications as prescribed. ot
completing the entire course of the prescribed antibiotics
regimen can lead to drug resistant pathogens and reactivation of
symptoms.