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Ineffective health maintenance related to infection of prior surgery site as evidenced by maggots in wound

Acute Pain related to dehiscement of incision as evidence by crying out in pain and stating pain is 8/10

Impaired skin integrity related to dehisced wound as evidenced by inflamed redness around wound and under pannis, and penis

Pt will display knowledge of splinting, while coughing, and verbalize understanding of hand/wound hygiene before leaving the hospital

Patient will verbalize pain 3/10 or an acceptable level within the hour of receiving pain meds.

To see signs of healing before leaving hospital

Ken and Jennie Nursing Concept map

1. Clean and dry inflamed skin. Rationale: promotes healing environment

2. Apply creams as prescribed on open areas. Rationale promotes healing

3. Explain importance of cleanliness. Rationale: Educating patient allows him to participate in own care.

4. Assess skin for further irritation. Rationale: Immobility can cause further irritation.

5 Encourage patient to rotate every 2 hrs. Rationale: to avoid pressure ulcers.

1. Stress importance of anti-biotic completion. Rationale: infection can mutates and cause for further infection

2. Teach importance of splinting abdomen for coughing and movement. Rationale: splinting can protect incision site reopening further.

3. Teach proper hygiene before dressing changes and before and after touching surrounding areas of the wound. Rationale: Don't want to spread infection and germs.

4. Teach importance of keeping wound properly dressed. Rationale: to allow proper healing.

5. Unpack, clean and repack wound with prescribe wound packing. Rationale: Wound can heal from inside out instead of closing with infection inside.

1. Teach patient to ask for pain medication to keep pain at a manageable level. Rational: getting pain meds before pain is too high can allow for smaller doses and more comfort.

2. Administer prescribed and PRN pain medication in a timely manner.. Rational: Pain medication will alleviate pain

3. Teach patient breathing and relaxation techniques. Rationale: Help relax patient to focus on something other than pain

4. Assess surgery site for further infection and tenderness. Rationale we can determine and treat infection before it worsens.

5. Teach and help patient to splint abdomen when moving and coughing. Rationale splinting can reduce pain

Lab results

Wound was debreided and has a good environment for healing. met.

Patient's stated pain never got below 4/10. The goal was not met, ongoing

Evaluation: Pt did spint to cough, but ignored teaching about hand/wound hygiene. The goal is ongoing/ partially met

Noncompliance related to alcohol, tobacco and marijuana use as evidenced by reluctance to change and coming to ED intoxicated.

Subjective Data

RBC 3.94 L↓ 4.5-6.0 Helps determine is the pt is anemic, pre surgery lab work

HGB 12.0↓L 14.0-18.0 ↓anemia, kidney disease

HCT 36.2↓L 42.0-51.0 Measures RBC % of total blood volume; ↓indicates anemia, dietary deficiency and/or rheumatoid arthritis. pre/post-surgery lab work

RDW 15.3 H↑ 12.0-15.0 ↑indicate iron deficiency anemia, sickle cell disease, hemolytic anemia and post- hemorrhagic anemia

Na 133↓L 137-145 ↓ CHF, CNS disease, hepatic failure

Creatine 0.6 L↓ 0.7-1.5 ↓in hyperthyroidism, liver disease or inadequate protein intake.

ALB 2.4 L↓ 3.5-5 lack of protein in diet, which causes insufficient healing of wounds

Ca 6.7↓L 8.4-10.2 ↓ indicate possible renal failure and diabetic ketoacidosis

Total Protein L 5.1↓ 6.3-8.2 Measure albumin ( help prevent fluid from leaking out of blood vesels) and globulin ( for the immune system)

Ultrasound was performed to determine picc line placement

Patient will verbalize understanding importance of smoking and alcohol cessation before the end of hospital stay.

Orders

Pt complains of dry mouth but refused mouth care. Pt says that his unstable HTN is due to radiation treatment he has had for prior cancer treatment. BP can be 148/60 and 10 min later be 216/110. Pt states it hurts too much to cough or use incentive spirometer, and needed lots of encouragement and redirecting to turn or move any of his extremities.

Perception of illness: Pt appears to be in denial and does not respond to questions pertaining to health care and acts like he is sleeping when social services came to see him. Affect: disinterested, anytime education about care for his wounds or teaching opportunities came up he said he was tired and did not care or stared off and did not respond

Emotional support: did not appear to have or want any support. No family nearby, girlfriend brought to ED, but has not been by to check on him. Report was given that Pt has been non compliant with medication regiment.

1. Educate the patient about the adverse effects of smoking and alcohol Rational: Smoking causes HTN and difficulty breathing and alcohol can cause cirrhosis of the liver and bad judgement.

2. Refer pt to support groups for smoking cessation and alcoholism. Rational social support has demonstrated the benefits to help people quit substance abuse.

3. Assess habits that put the patient at risk for substance abuse. Rational Having a plan of action when facing triggers, can help develop better choices.

4. Identify coping strategies for the patient to use instead of substances. Rational; developing coping strategies gives a different outlet to reduce stress.

Vitals ever 30 minutes

150 mL/ hour NS

NG tube continuous suction

I & O every hour

full assessment every hour

NPO

Wound dressing change once every 12 hrs

Not met, patient did not verbalize any interest in habit changing. Ongoing

Ineffective coping related to surgical wound as evidenced by "picking at own wound site" after being told by girlfriend not to do it.

Keep pt from picking at wound for duration of stay at the hospital.

Admitting Diagnosis

Objective Data

Medication

Dehisced abdominal wound

1. teach importance of cleanliness of wound site. Rationale: allow proper healing.

2. Assess skin for further infection Rationale: treating infection early can promote healing

3. Promote good overall hygiene. Rationale: Cleanliness provides healing environment.

4. Recommend good diet habit for proper nutrition and healing. Rationale: good nutrition promotes healing.

5. Explain sign and symptoms of further infection and steps to wound healing. Rationale: Educating the patient allows the patient to be involved in his care.

Evaluation: the patient has not touch wound during shift. The goal is met and ongoing

Enoxoparin (Lovenox) 40 mg/Sub Q/ q 24 h Anti-vascular, anticoagulant, hematologic anticoagulant Helps prevent DVT in pt who is undergoing abdominal surgery Induces thrombocytopenia, mild pain, hematoma hemorrhage, local irritation, erythema

Levofloxacin (Levaquin) in D5W 500 mg/IV Piggyback/ q 24 hr Fluoroquinlones Used for pnemonia

Metronidazole (Flagyl) in NaCl 500 mg IV 2 daily Antibiotic Used for anaerobic bacterial infections

Pantoprazole (Protonix) 40 mg/IV push 2x daily Proton pump inhibitor

Enalaprilat (vasotec) 0.625 mg/0.5 mL/ IV push PRN Ace inhibitor Used for hypertension

Push over 5 mins

Hydomorphine (dilaudid) 0.5 mg/ML IV push PRN q 2 hr. Opioid analgesic For pain

Magnesium replacement 1 bag PRN electrolyte Mild 1.5-1.7--Moderate 1-1.4--Severe < 0.9

Metoprolol tartrate (Lopressor) 5 mg/ 5 mL PRN Beta-one blocker, beta one selective used for hypertension, and long term treatment of angina pectoris. Administer with food or immediately after a meal

Ondasetron HCl (Zofran) PRN Antiemetic; Used for nausea and vomiting Assess client for N/V, abdominal distention, and bowel sounds before and after administration. Assess client for extrapyramidal effects periodically during therapy

Phosphorus IV replacement PRN Electrolyte Mild 1.7-2.4--Moderate 1.1-1.6--Severe <1.0

Potassium replacement PRN Electrolyte Mild 3.5-4.0--Moderate 3.1-3.4--Severe <3.0

VS: BP 128/84 P-59 R-16 T-97.5 O2 92% at 3L Pain 9/10

Mental Status: AO/ sedative with meds

Physical exam: Skin was color WNL dry, turgor was slow. 18 gauge IV on Left anterior arm. L arm had PICC line. Abdomen appeared irritated and inflamed abdominal surgical incisions 9-3-13 had dehisced with approximately 4 cm X 12 cm opening and another on the RUQ ab about 6 cm X 2.5cm. Pannis was also inflamed, and head of penis had a green/yellow pus ring around the top lip; when cleaned it bled. His toe and finger nails were very thick and untrimmed. Feet and fingernails had a very foul odor even though a through bed bath had been given the night before.

Head/Neck/Face: Pupils: PERRL, conjunctiva pink, Oral Cavity: dry, white tongue. no teeth( "I have dentures but do not wear them") Has NG tube in L nare on continuous suction that appears to be suctioning bile (dark green/brown). Assessment of Cardiovascular and Respiratory were normal: Pt has unstable HTN. Gastrointestinal: Diet-NPO abdomen very tender, absent BS X4 Pt IV normal Saline 150 ml/hr. Also received 1000 ml NS bolus because of low urine output Urinary Reproductive: Has indwelling catheter secured to RU leg. Low output 15-30 ml/hr. Neurological/musculoskeletal: verbal; unclear and soft spoken, Motor skills- seem slow, coordination-labored due to meds. Pt is on complete bed rest. Hand grips and foot pushes/pull are =/strong. Has full ROM no edema noted.

Discharged Planning

Client's Initials: ML

Age: 65

Marital Status: Single

Ethnicity: caucasian

Gender: Male

Code Status: Full

Is not religious, has a girlfriend

Lives alone staff thinks possible homeless

Date of Admission: 9-19-2013

Date of Assessment: 9-20-2013

Allergies: Penicillin causes swelling and rash

Height: 5'7"

Weight: 77.1 kg

Other Applicable Nursing Diagnosis

1. Discharge to long term rehabilitation facility for long term IV antibiotic treatment

2. Limit activities for next several weeks for recovery or until wound has healed

3. Educate about indicators of infection: abdominal pain, foul smelling discharge

4. Importance of high fiber/high protein/increase fluid intake of at least 2-3L/day.

5. Importance of follow-up care, follow through with doctor appointments and instructions.

6. Importance of cleanliness to wound sites

7. Refer patient to a support group for alcohol and smoking cessation and its health benefits

8. Social Service referral for home living situation

Pathophysiology

Risk for infection

Dysfunctional gastrointestinal motility

Risk for ineffective renal profusion

Risk decreased cardiac tissue perfusion

Risk for ineffective gastrointestinal profusion

Knowledge deficit

Risk for falls

Smoking Cessation

Ineffective Self Help management

Risk for Powerlessness

Risk for Self-mutilation

Risk for contamination

Risk for impaired liver function

Impaired comfort

social isolation

sleep deprivation

Risk for ineffective activity planning

Impaired physical mobility

risk for imbalanced fluid volume

Bathing self-care deficit

toileting self-care deficit

self-neglect

disturbed body image

Dressing self-care deficit

feeding self-care deficit

Contamination

Delayed surgical recovery

situational low self-esteem

impaired tissue integrity

Relevant health history

Lack of hygiene --> caused itching at wound site --> scratching --> infection --> inflammation --> dehiscement of surgical wound.

Dehisccement occurs with a bursting open of a surgical abdominal wound; to avoid: proper nutritional status and risk factors such as malnurishment before surgery, supporting wound during coughing and movements that strain the incision (Venes, 2009).

Smoker

Social marijuana user

Occasional alcohol use

history of colon cancer

COPD

uncontrolled HTN

post operative colostomy revision and small bowel revision 9-3-13

References

Patient was brought to ED by girlfriend complaining of abdominal pain. Girlfriend had stated in ED that she thought his surgical incision was infected and "he was picking and gouging at it for the past couple of days". Upon assessment in the ED, RN found that the wound had dehisced and had fecal matter in it and was full of maggots. Patient was admitted for surgical debreidment of prior surgical site. ED stated to floor nurse that patient was intoxicated upon arrival.

Pagana, Kathleen Deska, PhD, RN. Timothy J Pagana, MD, FACS.

MosbyDiagnostic Labatory Test Reference sixth edition. (2003). St Louis. Mosby Inc. Elsevier Science.

Venes, Donald. M.D., MSJ. (2009). Tabers cyclopedic medical dictionary edition

21. Philadelphia. F. A. Davis Company

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