Client: Victoria Remy – 34-year-old female diagnosed

Client: Victoria Remy – 34-year-old female diagnosed with a post op infection and wound dehiscence. Goals of Care: R1 Allergies: Demerol, Sulfa and Talc Powder Past Medical History- Crohn’s disease, anxiety, 5 day’s post op transverse ostomy reversal. The client was admitted from emergency to your unit this morning at 0100. Upon arrival on the unit, the client was experiencing 6/10 non-radiating pain to dehisced wound to left upper quadrant. Wound care in the emergency department noted seropurulent drainage and wound dressing was completed at approx. 1500 hours. Admission Vital signs were T- 37.8 Pulse 89, regular and strong Resp 18- Free and easy, BP 129/83 and 97% on Room air. IV insitu to left forearm, running NS @ 125cc/hr. The client is ambulating with assistance due to pain. Labs: CBC completed in emergency with result the only abnormal result being a WBC of 15.2. Other labs completed were Lytes/BUN/Creatinine and GFR. For repeat labs in the at 1000. Medications: Cefazolin 750 mg IV q8hours, Metronidazole 500mg PO BID, Sertraline- 50mg po daily, Morphine 5mg SC q4-6 hours prn and 1 hour prior to dressing change, Tylenol 650 mg po q4-6 hr prn, Ativan 0.5mg SL BID prn. Appropriate Nursing care plan: Identify the priority nursing diagnosis. A SMART goal for the DX Identify three interventions to address this priority diagnosis o Include an intervention to address 1. Nursing care, 2. Medication Administration, & 3. Education needed o Identify the evaluation criteria that will be used to assess effectiveness of care o Identify the rationale for the priority dx, interventions, evaluation criteria, etc. SCIENCE HEALTH SCIENCE NURSING XHLT 1510

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