Transcript Bertha Banner

Bertha Banner
Diagnosis: Post-cesarean
surgical site infection,
obesity
Age: 42
Weight: 183lbs/83kg
Height: 62cm
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Marital status: married to Bruce Banner
Cultural information: Jehovah’s Witness
Economic status: middle class
Dwelling: apartment above bakery
Job: Baker/entrepreneur
Main support/care giver: husband
Other pertinent information: poor nutrition, hypertension, limited activity, arthritis,
high cholesterol, 4 children, chronic lumbar pain
Admitting Diagnosis
• Infection along post-cesarean surgical site
• Pain due to infection in abdomen area
• Obesity
Orders
• Diet
• Low sodium diet
• Activity
• Up with bedside commode
• Out of bed 3x’s a day
• Encourage bathing on her own, be sure to keep wound dressings dry
• Medication
• Antibiotics
• Watch for nausea due to antibiotics
Priority Nursing Diagnosis
• Pain management
• Infection control
• Impaired physical mobility due to pain caused by post-caesarian infection
Patient Outcome/Goal
• Patient will report a decrease in pain (0-1/10) and shows no grimacing or
signs of discomfort at end of hospitalization.
• Eliminate any infection from the caesarian wound to help improve patient’s
mobility.
• Patient will state the signs and symptoms to be aware of at the end of
hospitalization.
• Patient will demonstrate how to walk without assistance from a person or
equipment (walker/cane).
Nursing Interventions
• Assess patient for pain every 2 hours
• Obtain any assistive device to help when patient is up out and of bed.
(Commode)
• Monitor and record the patient's ability to tolerate mobility
Nursing Interventions Rationale
• “Relieving pain and suffering is more than giving pain medications, repositioning
the patient, or cleaning a wound. The relief of pain and suffering encompasses
caring nursing actions that give a patient comfort, dignity, respect, and peace.
Ensuring that the patient care environment is clean and pleasant and includes
personal items makes the physical environment a place that soothes and heals the
mind, body, and spirit” (Gallagher-Lepak and Kubsch, 2009,pp. 85).
• Have clients use a commode or urinal for toileting and avoid use of a bedpan.
Getting out of bed to use a commode or urinal does not stress the heart any more
than staying in bed to toilet. In addition, getting the client out of bed minimizes
complications of immobility and is often preferred by the client ( Winslow, 1992,
pp.182) (Ackley and Ladwig, 2011, pp. 85 ).
Evaluation of Patient Outcome/Goal
• Patient reported decreased pain level (2-10) and verbalized understanding to
resume her pain medication at home.
• Patient verbalized understanding the signs and symptoms of infection if she
was to contract another infection and to contact her health care provider.
• Patient was able to demonstrate correct way to walk without assistance of a
person or equipment.
• Patient also understood the benefits and importance of exercising to help
with mobility.
Day # 2
• Today you are assigned to Bertha again. Overnight she
refused to move or walk in the hallway. This morning she
is complaining of shortness of breath. During your
assessment you note that she is breathing rapidly, warm to
the touch and complaining of light headedness.
• What is you priority nursing diagnosis for Bertha today?
• Write a care plan based on your diagnosis.
Works Cited
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Ackley and Ladwig, 2011, pp. 85
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Low Sodium [Online Image]. Retrieved September 8, 2015 from http://www.dietsinreview.com/images/cache/450x300_lowsodium.jpg
Gallagher-Lepak and Kubsch, 2009, pp. 85
Winslow, 1992, pp. 182
Bedside Commode [Online Image]. Retreived September 8, 2015 from http://www.galaxymedical.net/bedside-commodes
Stetoschope [Online Image]. Retrieved September 8, 2015 from http://phoenixrising.me/wp-content/uploads/Diagnosis1.jpg
Bakery House [Online Image]. Retrieved September 8, 2015 from http://www.thebakeryhouse.net/images/img_7266.jpg
Melissa Mccarthy [ Online Image]. Retrieved September 8, 2015 from http://thevintagepress.co/photos/melissa-mccarthy/melissamccarthy-thin-5401cdc7ead2b12480c9c8e0d04136f4-big-356954.jpg