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51 y.o. Hispanic male who reported to the ED with dyspnea and an infection…
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An infection occurs when a pathological organism multiplies in the body causing an inflammatory response in the host.
Nursing Diagnosis: Impaired tissue integrity r/t infection AEB damage to tissue on foot, localized pain, area affected is swollen and tender.
Interventions: monitor site of impaired tissue integrity for color changes, changes in drainage; Provide tissue care as needed; administer antibiotics as ordered; avoid rubbing the area and protect it while ambulating; encourage a high-protein, high calorie diet; pt education r/t wound and skin care.
Goal: patient demonstrates understanding of teaching r/t skin and wound care; patient verbalizes measures to protect feet from further tissue damage.
Nursing Diagnosis: Acute pain r/t wound on right foot AEB patient pain rating of 9/10.
Interventions: Acknowledge reports of pain immediately and determine the proper pain relief method; create a minimally stressful environment to promote relief, sleep and relaxation; use of nonpharmacological methods for pain relief (e.g. imagery, distraction techniques and relaxation exercises)
Goal: Patient will express a tolerable pain level by end of shift (4/10).