Nursing Diagnosis
Subjective/Objective Data (AEB)
Nursing Interventions
Rationale(s)
Goals
Outcome(s) Evaluations Infection Actual, related to, inadequate primary defense occurring with disruption of the GI tract, disruption of the integument and underlying tissue, multiple indwelling catheters and drainage tubes, compromised immune state caused by invasion on pathogenic bacterium secondary to bacteremia and endocarditis as evidence by:
Tachycardia (HR 106)
Varying fever (99-102)
Decrease Albumin(2.9)
Positive Blood cultures (Staph and Klebsiella)
Echocardiogram and Transesophogeal-
Echocardiogram showing vegetation in the right atrium.
Increased WBC (16.5) Neutrophil (89) and Monocyte (15.7)
52 yo female
Presented to ER on 8/12/14 c fever of 104 and abdominal pain, had a peg tube, endocutaneous abdominal fistula and colostomy bag in place.
C/O Fever
Admitting Dx: Small bowel obstruction , Sepsis
PMHx: Back Problems, GERD, Hypothyroidism, Pancreatitis, Anemia
Surgical Hx: Gallbladder, Hysterectomy,
Current physician: Ratliff, Fadi, Wright
Assessment:
A&O x3
Pain 4/10 abdomen, “ dull constant pain”
Speech clear and appropriate
Skin very warm , feel feverish to the touch, dry and pink Temperature 102.4
Perrla
Nares, clear, symmetrical
Mucous membranes pink moist intact
No swelling in face
Right jugular central line 18 guage lumen infusing TPN ( Aminosyn 10% with ½ NS @ 50 ml/ hr)
Chest symmetrical
Respirations even and unlabored rate of 14
Patient is eupneic
O2 sat 98 room air
Absent of retractions and nasal flaring
Apical pulse 106
Heart sounds audible S1 and S2
Turgor elastic, no tenting
Cap refill 3 sec nail beds pink skin warm and dry
Hand grips strong and equal bilateral
Radial/ brachial pulses strong and palpable +2
Full active Range of motion
Bowel sounds presents, hypo active.
Abdominal Fistula draining to colostomy bag mid abdomen, drainage is yellow and cloudy. Intact no redness or edema noted around fistula no skin break down noted
RUQ Peg tube draining to cath bag with 800 ml of yellow cloudy drainage in bag, insertion site of peg tube is covered with 4x4 there is no redness or leakage around site, bandage is dry.
3cm x 4 cm area of skin break down in the epigastric region, covered with wet sterile gauze and 4x4, no drainage or odor from the wound the edges are well approximated.
No abdominal distention
No constipation or diarrhea
Urine is yellow an clear, freely voids and is continent no pain on urination
Cap refill 3 sec Nail beds pink ,
Pedal pulses strong and equal bilateral rate of 106
Pedal pushes strong and equal.
No edema in lower extremity
Vital signs : 1005 am
BP: 110/63
HR:106
R: 14
O2: 98 room air
Temp 102.4
Pain 4/10
Wt: 150#
Ht: 5ft 2in
BMI 27.6
Intake and out put
Patient in NPO
Intake 2552ml from TPN and IV fluids in 24h
Output: 2650ml/24h
Subjective data:
Patient explained how she got the fistula “ I had a gallbladder surgery in February, the surgeon cut my bowel and my bowel content spilled over into my gut causing me all kinds of issues, I have been in and out of the hospital since then I was in the hospital several times during the month of July at UK, I to have the peg to up in to drain the fluid off of me the fistula developed because of the complications from the gallbladder surgery, I have to have the picc line put in and the the tpn bc of all the infections and I just can’t eat any more, But im still tankful I am alive”
Diagnostic testing:
8/12/14
Blood Cultures: Gram positive Tetrads and Clusters non hemolytic staphylococcus. Aerobic Culture: Moderate growth of lactose fermenting Gram negative rod Klebsiella Pneumonia Bacteremia.
CXR: No acute cardiopulmonary process. Stable heart size. RUE picc
