RNSG 2360 Mini Nursing Care Name: Katie Ruth MCP# PNE6379 Date: 3/18/19

Initials: RL Age: 50 Gender: M Date of admission: 2/20/19 VS: BP: 149/90 HR: 76 R: 18 T: 98.6 Wt: 86kg
Dx on admission: Osteomyelitis of right calcaneus and abdominal pain

Pathophysiology Statement: Osteomyelitis is an infection in a bone. An infection can reach a bone through the
bloodstream or spreading from nearby tissue. Infections can also start in the bone itself if an injury exposes the bone
to germs, examples of this would be deep puncture wounds and open fractures. Most cases of osteomyelitis are caused
by staphylococcal bacteria. People who smoke and people with chronic health conditions, like diabetes and kidney
failure are more at risk of developing a osteomyelitis. Diabetics with foot ulcers may develop osteomyelitis.
(“Osteomyelitis”, 2018)

New Dx or co-morbidities: Pt has a past medical history of DM, HLD, HTN, neuropathy, kidney failure, cirrhosis of
the liver, and hepatic encephalopathy. Pt also has a history of smoking.

Nursing Diagnosis Intervention/Actions Outcomes/Evaluation

Acute pain r/t right calcaneus foot -Assess pain location, Pt. will report decreased pain of
wound AEB pt. statement, “my characteristics, onset, duration, and at least a 3 on a scale of 1-10.
pain is a 5 out of 10.” aggravating and relieving factors Pt. shows increased comfort
-Wound care through a decreased pulse, BP,

m
-Dressing changes and respirations

er as
-Encourage pt. to consume high

co
protein meals

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-Encourage ambulation if/when

o.
patient is able.
rs e -Monitor vital signs
ou urc
-Administer medications
Risk for unstable blood glucose r/t -Monitor pt’s blood glucose levels Pt. blood glucose levels
ineffective diabetes management before meals checked and appropriate
o

AEB HbA1C of 8.7 -Administer insulin amount of insulin given

aC s

-Consult with diabetes nutritionist according to sliding scale. Pt.

vi y re

-Assist pt. in choosing appropriate demonstrated use of

nutrient rich, low sugar food choices glucometer and acknowledged
-Teach pt. about lifestyle changes – she needs to eat healthier.
diet and exercise Request put in for pt. to see
ed d

-Have pt. demonstrate use of nutritionist. Pt’s meals are low

ar stu

glucometer. sugar, low fat.

Risk for impaired skin integrity -Assess general condition of the skin Patient’s skin remains intact, as
AEB fecal and urinary -Assess pt’s awareness of sensation evidenced by the absence of
is

incontinence and pressure redness in perineal area.

-Reposition patient Q 2 hours.
Th

-Encourage ambulation if/when

patient is able
-Answer call light quickly
-Keep perineal skin clean, dry, and
sh

apply a protective ointment or cream

to perineal area as indicated by
incontinence
-Consult a continence nurse
-Use absorbent pads that effectively
absorb moisture and keep it away
from skin

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 Medication Category/Indication Side effects Medication Category/Indication Side effects
Doxycycline
Test/Date
Anti-infective
Results
-diarrhea Lactulose
Interpretation/Relevance to Dx
Laxatives / -cramps
Treatment/Intervention/Outcome
Tetracycline / -nausea Constipation, -abdominal
X-ray right foot Osteomyelitis + osteomyelitis
-vomiting
of right calcaneus Hepatic
Surgery, IV antibiotics / wounddistention
care / Removing
-photosensitivity encephalopathy
infected bone and stopping -flatulence
infection
Zofran
Abdominal Anti-emetic / Nausea + cirrhosis
-headache of the liver Metoprolol Beta
Medications to blocker
slow the/ progression
HTN -fatigue
/ administer
pelvic CT with and vomiting -constipation medications, low sodium diet, monitor -weakness
labs / Pt. will
contrast -diarrhea avoid complications and have a slower -bradycardia
the progression
Lasix
Ammonia Diuretic
44 / Edema, -dehydration
High / ammonia Dilaudid
in brain, hepatic Opiod
Lactulose / Pain / lower levels
/ monitor -constipation
of ammonia
renal disease encephalopathy
-hypokalemia -sedation
GFR 37 -hypocalcemia
Low filtration / kidney failure Continue to monitor -confusion
-hypomagnesia -hypotension
Effexor
HbA1C Anti-depressant
8.7 / -anxiety
High / Poor diabetes management Heparin Anticoagulant /
Give medication insulin, monitor -increased risk of
blood glucose,
Major depressive -dizziness
over 3+ months Prophylaxis DVT bleeding
consult a nutritionist, teach lifestyle changes including
disorder -insomnia diet and exercise. Pt’s HbA1c will-anemia
decrease through
-nervousness interventions.
Prioritize Complications: Risk, Actual, Urgent, or Emergent

Priority Complication/Indication Expected Orders/ Nursing Actions /Rational Expected or Actual

Rational Outcome/Evaluation
Actual Hepatic Administer Administer lactulose Minimize progressive
encephalopathy / Lactulose and and diuretics as liver damage, optimize

m
increased ammonia diuretics prescribed, provide nutrition, maximize

er as
levels Serial monitoring adequate nutrition, hepatic circulation,

co
of blood ammonia vitals and respiratory minimize and prevent

eH w
levels assessment, monitor respiratory

o.
fluid and electrolyte complications
rs e balance
ou urc
Risk Falls / Pt. is connected Do not ambulate Keep call light in Pt. will ask for
to IV and oxygen. without assistance / reach, pt. can call assistance when
fall risk precautions nurse when wanting to ambulating and remain
o

ambulate / Answer call free from falls

aC s

light quickly, round on

vi y re

patient frequently
Actual Hypervolemia / Stop NS, Stop IV Remove fluid –
Pt.will have fluids
pulmonary crackles Lasix diuresis, Auscultate pt
removed and clear
lungs sounds, monitor
breath sounds with
ed d

intake and output, and

absence of pulmonary
ar stu

weight, Monitor and

crackles, Patient is
note BP and HR,
normovolemic as
assess for presence of
evidenced by urine
edema. output greater than or
is

equal to 30 mL/hr.
Th

balanced intake and

output and stable
weight.
Collaborative Disciplines: ED, Hospitalist, podiatry, nephrology, wound care, radiology, infectious diseases, nutrition
sh

Communication/Delegation (who, what, when , justification): Patient

care tech provided vitals for shift. Patient care tech
notified nurse that pt’s blood glucose level was 55. Nurse stayed with patient and delegated to me to get orange
juice and peanut butter. I took pt’s blood glucose after 15 minutes it was 91.

Reference:
Gulanick, M. & Myers, J.L., (2017). Nursing Care Plans (9th Ed.). St. Louis, Mo: Elsevier.

Haugen,
This study N. (2011).
source Ulrichby&100000788210777
was downloaded Canale’sS Nursing Care Planning
from CourseHero.com Guides.
on 03-25-2021 21:34:56 7th
GMTed. [S.l.]: Saunders.
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 Osteomyelitis. (2018, November 16). Retrieved April 7, 2019, from https://www.mayoclinic.org/diseases-
conditions/osteomyelitis/symptoms-causes/syc-20375913

m
er as
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o.
rs e
ou urc
o
aC s
vi y re
ed d
ar stu
is
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sh

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