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Published byRose Moore Modified over 8 years ago
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Cam Newton
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Background 28 years old male 5’10” 160lbs Asian-Indian IT Consultant Married with 3 children Live in 2 story house
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Reason For Admission MVA Broken left femur Abrasions on face and chest Stitches on face and chest CT & Xray ordered Femur repair surgery scheduled Concerns: Concussion, infection, and pain management Past Health: Chronic back pain and poor circulation to lower extremities
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Orders Toileting: foley & bed pan Activity: bed rest Diet: NPO (because of upcoming surgery) Bathing: bed bath with assistance Special considerations: ortho bed with trapeze Fall risk
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Nursing Diagnosis/Planning Bathing self-care deficit related to MVA, evident by left broken femur. Impaired physical mobility Risk for infection related to break in the skin, as evident by abrasions Primary Nursing Diagnosis Risk for infection related to break in skin, as evident by abrasions.
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Patient Goal No infection by proof of absence of redness/swelling of abrasions, WBC within normal range by end of shift.
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Nursing Interventions Bathe patient daily Maintain dry dressings during bathing Notify physician if dressings get wet Report back any findings related to dressings Reasoning: Hygiene care is important for infection control and keeping the patient comfortable. Keeping the dressing(s) dry will prevent bacterial growth.
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Day # 2 – Cam Newton You have returned the next week and are assigned to Cam again this shift. Cam had some complications related to infection and his surgery to fix his femur was delayed. He is not POD#2. He is still on bedrest and has a CPM machine on his left leg. Physical Therapy will start working with him tomorrow. During your assessment you ask Cam when his last bowel movement was and he states that was prior to his accident over a week ago. What would his priority nursing diagnosis be today? Write a care plan based on the priority diagnosis.
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