Assessment Data Problems: Immunity:
Positive Outcomes
1. Patient will exhibit improved immune response as evidenced by a
Physiological process by
M.B 45-Year-old Caucasian male decrease in local signs of infection around the fractured ankle, such as
which one is resistant to reduced swelling, redness, and warmth, within the next 48 hours.
disease. 2.. Patient will demonstrate effective management of their fracture and
Admitted to the hospital on 09/05/24
immune system support, resulting in stable or improved laboratory
Patient Concept Nutrition, Mobility markers of immune function
Dx: Worsening left foot pain and swelling, unable to bear weight on injured leg
3. Patient will maintain optimal wound and skin integrity around the
fracture site, as evidenced by no new signs of pressure ulcers or skin
Hx: congestive heart failure, obesity, diabetes with neuropathy, HTN, COPD, GSW breakdown, and will follow prescribed preventive measures
Patient Goal
Outcomes 1Patient will apply prescribed topical antibiotics to the fractured ankle
and document the application in the care log by the end of the shift
today.
2. Patient will take all prescribed medications for pain management and
Antecedents Interventions immune support as scheduled, documenting each administration and any
Negative Outcomes
1. Functional lymphatic system, optimal innate side effects in the medication log by the end of the shift today.
Potential complications to
immune response. 3. Patient will elevate the fractured ankle and perform prescribed range-
screen for and preventative
2. Optimal nutrition status/adequate nutrition of-motion exercises at least 3 times during the shift, recording each
measures
3. Adequate energy, muscle instance in the care log by the end of the shift today.
strength, neuromuscular coordination
Infection Patient Education
Patient Priority Problem Immunity
(Tertiary Prevention)
1.Monitor patient’s wound and report any signs and symptoms of 1.Instruct the patient and family on
1. Monitor the patient for signs of secondary infections or complications related to
infection including redness,swelling,increased pain or purulent
their condition, such as increased temperature, redness, or swelling at the injury proper techniques and hygiene for
discharge.
site. wound care.
2.Assess patient’s nutritional status and review diet. Make sure
2. Encourage patient to optimize their intake of protein and calcium, to support 2. Educate patient on the signs and
patient gets enough protein and eats a balanced diet.
bone healing and tissue regeneration.
3.Maintain a strict aseptic process for patient’s dressing changes, symptoms of an infection, and also
3. Implement and adhere to strict infection control protocols to manage and
prevent complications associated with immune system compromise.
including proper hand hygiene to prevent delayed wound healing worsening infection and when to
and spreading of pathogens. alert the provider.
3. Encourage patient to adhere to the
prescribed diet, and to consume
protein rich foods.
Priority Problem # 2 Interrelated Concept: Nutrition Poor wound healing 4. Refrain from drinking regular
1. Recommend supplements such as vitamin c,k and magnesium for proper bone pepsi, and instead drink diet pepsi.
mineralization. 1.Educate the patient on the body’s nutritional needs, and also submit
2.Provide ongoing education about balanced diets, and refer client to a nutritionist for a referral for a dietician.
or other specialist to help create meal plans. 2.Encourage the patient to adhere to their carb control diet, and
3.Ensure that patient consumes enough calories to support the increased consume adequate amounts of protein and vegetables.
metabolic demands of healing. 3.Monitor patient’s lab values and review patient’s chart for their diet Teamwork and Collaboration
chosen by the provider
Nurse
Infectious disease doctor
Priority Problem #3 Interrelated Concept: Mobility Nutritionist
1.Assess the client’s mobility status and their needs for assistance, such as Fall Orthopedics
completing ADLS using the FIM. 1.Assess environment for trip/fall hazards, and ensure the bed is doctor/surgeon
2.Determine client’s activity tolerance level, as this will be effective in creating the always in a locked and low position. radiologist
best possible plan for the patient. 2. Inform the patient to utilize the call light when they need to get up
3.Identify factors that are affecting the client’s ability to ambulate, such as
Wound care nurse
or go to the restroom, especially if they recently began a new
pain ,motivation, continence,etc. PT
medication.
3.Educate patient on fall safety precautions, such as throw rugs at home which 3.Encourage the use of assistive devices such as the patient’s walker, OT
may cause falls and also to replace dull lights with bright light. which helps to keep patient mobile and lessens risk of fall. Case manager
Positive Outcomes
1. Patient will exhibit improved immune response as evidenced by a
Physiological process by
M.B 45-Year-old Caucasian male decrease in local signs of infection around the fractured ankle, such as
which one is resistant to reduced swelling, redness, and warmth, within the next 48 hours.
disease. 2.. Patient will demonstrate effective management of their fracture and
Admitted to the hospital on 09/05/24
immune system support, resulting in stable or improved laboratory
Patient Concept Nutrition, Mobility markers of immune function
Dx: Worsening left foot pain and swelling, unable to bear weight on injured leg
3. Patient will maintain optimal wound and skin integrity around the
fracture site, as evidenced by no new signs of pressure ulcers or skin
Hx: congestive heart failure, obesity, diabetes with neuropathy, HTN, COPD, GSW breakdown, and will follow prescribed preventive measures
Patient Goal
Outcomes 1Patient will apply prescribed topical antibiotics to the fractured ankle
and document the application in the care log by the end of the shift
today.
2. Patient will take all prescribed medications for pain management and
Antecedents Interventions immune support as scheduled, documenting each administration and any
Negative Outcomes
1. Functional lymphatic system, optimal innate side effects in the medication log by the end of the shift today.
Potential complications to
immune response. 3. Patient will elevate the fractured ankle and perform prescribed range-
screen for and preventative
2. Optimal nutrition status/adequate nutrition of-motion exercises at least 3 times during the shift, recording each
measures
3. Adequate energy, muscle instance in the care log by the end of the shift today.
strength, neuromuscular coordination
Infection Patient Education
Patient Priority Problem Immunity
(Tertiary Prevention)
1.Monitor patient’s wound and report any signs and symptoms of 1.Instruct the patient and family on
1. Monitor the patient for signs of secondary infections or complications related to
infection including redness,swelling,increased pain or purulent
their condition, such as increased temperature, redness, or swelling at the injury proper techniques and hygiene for
discharge.
site. wound care.
2.Assess patient’s nutritional status and review diet. Make sure
2. Encourage patient to optimize their intake of protein and calcium, to support 2. Educate patient on the signs and
patient gets enough protein and eats a balanced diet.
bone healing and tissue regeneration.
3.Maintain a strict aseptic process for patient’s dressing changes, symptoms of an infection, and also
3. Implement and adhere to strict infection control protocols to manage and
prevent complications associated with immune system compromise.
including proper hand hygiene to prevent delayed wound healing worsening infection and when to
and spreading of pathogens. alert the provider.
3. Encourage patient to adhere to the
prescribed diet, and to consume
protein rich foods.
Priority Problem # 2 Interrelated Concept: Nutrition Poor wound healing 4. Refrain from drinking regular
1. Recommend supplements such as vitamin c,k and magnesium for proper bone pepsi, and instead drink diet pepsi.
mineralization. 1.Educate the patient on the body’s nutritional needs, and also submit
2.Provide ongoing education about balanced diets, and refer client to a nutritionist for a referral for a dietician.
or other specialist to help create meal plans. 2.Encourage the patient to adhere to their carb control diet, and
3.Ensure that patient consumes enough calories to support the increased consume adequate amounts of protein and vegetables.
metabolic demands of healing. 3.Monitor patient’s lab values and review patient’s chart for their diet Teamwork and Collaboration
chosen by the provider
Nurse
Infectious disease doctor
Priority Problem #3 Interrelated Concept: Mobility Nutritionist
1.Assess the client’s mobility status and their needs for assistance, such as Fall Orthopedics
completing ADLS using the FIM. 1.Assess environment for trip/fall hazards, and ensure the bed is doctor/surgeon
2.Determine client’s activity tolerance level, as this will be effective in creating the always in a locked and low position. radiologist
best possible plan for the patient. 2. Inform the patient to utilize the call light when they need to get up
3.Identify factors that are affecting the client’s ability to ambulate, such as
Wound care nurse
or go to the restroom, especially if they recently began a new
pain ,motivation, continence,etc. PT
medication.
3.Educate patient on fall safety precautions, such as throw rugs at home which 3.Encourage the use of assistive devices such as the patient’s walker, OT
may cause falls and also to replace dull lights with bright light. which helps to keep patient mobile and lessens risk of fall. Case manager
