LAC School of Nursing
NURSING CARE PLAN
N233 L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Due on the 6th week of each MedSurg rotation
Student Name: Liliana Curiel __ Admit Date: 10/15/2023
POD# N/A
Pt initials: AA Room #: 105A Age: 75 Gender: Male Ethnicity: South American Psych Hold: N/A Ht: 183 cm Wt.: 105.20
Current Medical Diagnosis:
Osteomyelitis of the left foot
Resolved Medical Problems:
Chief complaint: Left Foot discharge getting worse
All Secondary Diagnosis: CHF,
MRSA, HFeEF, Diverticulosis, iron
deficiency anemia
Current Abnormal Nursing Assessment
Abnormal & Pertinent Labs
Current Orders
Bilateral leg
swelling
Allergies (reactions): NKA
Code Status: FULL
IV Site: Left Antecubital 20 gauge
AST: 21 → AST + ALT → due to
inflammation from his foot infection lead to
liver stress causing enzymes to be
elevated
ALT: 13 →
IV Fluids: Flagyl, vancomycin
Ordered Tx: antibiotics, wound care, possible
amputation
Diet: consistent carbohydrate diet
Alcohol No Yes X Type Wine every day last used before admission
Drugs No X
__Amount/day
_Last use: _____
Activity: weight bearing:: wear heel offloading boot
Caffeine No
on both legs to be worn at all times while in bed,
Pathophysiology: Osteomyelitis is an infection of the bone,
typically caused by bacteria but sometimes fungi. The
pathophysiology of osteomyelitis involves the invasion of
microorganisms into the bone, leading to an inflammatory
response
and potential damage to the bone tissue.
JIJI
elevate both legs when seated or sleeping
Fall Risk/Safety: yes, uses wheelchair, unable to
ambulate due to left foot injury
Skin issues: bilateral lower extremity edema, left
ankle wound s/p ankle surgery.
Significant Family Hx: father: HTN, malignant lung
tumor
Prior Health Problems
(State Significance)
Albumin: 3.1 → may be due to fluid
overload from heart failure and his
bilateral lower extremity swelling, MRSA,
and osteomyelitis. This leads to an
increase leakage of albumin into tissue
HGB: 9.4 →HCT & HGB HF & chronic
infections can lead to anemia due to
decrease production of RBC or chronic
inflammation
HCT: 30.2 →
MCV: 76.7 → lack of iron, patient was
given iron supplement at
Diagnostics with Results/
Significance
X RAY of left ankle: generalized
osteoporosis w/overlying soft tissue
prominence, curvilinear vascular
calcifications and fibula left ankle
cutaneous abrasions as well as ulcer
crater; as compared with 5/12/23
2. Aligned left ankle
3. Mild left hindfoot charcot
arthropathy
4. Minimal degenerative changes of
left ankle joint
LAC School of Nursing
NURSING CARE PLAN
N233 L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Due on the 6th week of each MedSurg rotation
Copying from the textbook or electronic source does not constitute satisfactory preparation
Medication:
Classification: iron product
Assessment: access patients level of fatigue, any GI issues
Generic Name: Ferrous Sulfate
Indication: Hx Heart failure, increase RBC to keep good
circulation of oxygenated blood to effected foot.
Labs: CBC
Dose/Route/Frequency:325 mg
QotherDay, PO
Time: 0900
Last Dose Given: no previous dose
charted.
How does it work? : Iron combines with porphyrin and
globin chains to form hemoglobin, which is critical for
oxygen delivery from the lungs to other tissues.
Teaching: coffee, tea, milk, cereal, dietary fiber, and
phosphate containing drinks decrease absorption. Antacids
decrease absorption
Adverse Effects: GI issues, blackened stools, nausea,
epigastric pain
Recommended/Usual Dose/Max
Dose:
Black Box Warning:
Medication: Lasix
Classification: loop diuretic; antihypertensive
Assessment: check the blood pressure per order
Generic Name: furosemide
Indication: HTN, lower extremity edema
Labs: Electrolytes, Lipids, CBC
Dose/Route/Frequency: 20 mg, PO,
QDAY
How does it work?: inhibits sodium and chloride
Teaching: frequent urination, don’t get up too fast, avoid
reabsorption at the proximal and distal tubules as well as becoming dehydrated, ETOH increases chance of side effect,
the ascending loop of Henle.
avoid too much direct sunlight, wear SPF.
Time: 1000
Last Dose Given: 10/17 @ 1032
Recommended/Usual Dose/Max
Dose:
Adverse Effects: hyponatremia, hypochloremia,
hypokalemia, blood cholesterol increased, blood uric acid
increased, gout.
Black Box Warning:
LAC School of Nursing
NURSING CARE PLAN
N233 L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Medication: Lopressor
Classification: beta-blocker
Generic Name: metoprolol
Indication: hypertension
Dose/Route/Frequency: 100 mg, PO,
Q12h
Time: 0800
Last Dose Given: 10/17 @ 0806
Due on the 6th week of each MedSurg rotation
Assessment: BP and HR, do not give if HR is less than 60
bpm. Hold if SBP less than 90 mmHg
Labs: AST, ALT
How does it work?: selectively blocks beta-1 adrenergic
receptors in the heart at lower doses; also inhibits beta-2 Teaching: stand up slowly to prevent orthostatic
adrenergic receptors in the bronchi and peripheral
hypotension and prevent fall risk. Do not give if HR less than
vessels at higher doses
60 bpm, continue to monitor you BP, take as prescribed.
Adverse Effects: bradycardia, hypotension, allergic
reaction, SOB, dizziness, tired.
Recommended/Usual Dose/Max
Dose:
Black Box Warning:
Medication:
Classification: antibiotic
Generic Name: sodium hypochlorite
topical
Indication: infection of the patients foot
Assessment: assess the skin that is being treated, monitor
for any changes or signs of an allergic reaction
Labs: WBC,
How does it work?
Dose/Route/Frequency: 1
application, topical, QDAY
Adverse Effects: allergic reaction, reddening of the skin
Time: 1000
Black Box Warning:
Last Dose Given: no previous dose,
charting states “not appropriate at
this time” for previous days
Recommended/Usual Dose/Max
Dose:
Teaching: stop if severe redness or irritation of treated skin,
apply over affected area.
LAC School of Nursing
NURSING CARE PLAN
N233 L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Due on the 6th week of each MedSurg rotation
Medication: flagyl
Classification: antibiotic, antimicrobial agent
Assessment: assess the IV site, WBC,
Generic Name: metronidazole
Indication: osteomyelitis
Labs: WBC, LFT
Dose/Route/Frequency: 500 mg, 100 How does it work? Exerts its antibacterial effects in an
Teaching: report any neurological symptoms, may be GI
mL IVPB, Q8h,
anaerobic environment against most obligate anaerobes. upset, and continue meds as ordered to help with the
It enters the organism via passive diffusion into the
infection.
cytoplasm of the susceptible organism where it is
Time: 1200
reduced. Following reduction, this drug can interact with
DNA, leading to inhibition of DNA synthesis and DNA
Last Dose Given: 10/16 @ 1139
degradation, causing death of bacteria.
Recommended/Usual Dose/Max
Adverse Effects: HA, abnormal urine, nausea, myalgia,
Dose:
angioedema,
Black Box Warning:
Medication: Tylenol
Classification: analgesic/anti-pyretic
Assessment: Pain scale, follow-up
Generic Name: acetaminophen
Indication: for pain or fever as needed
Labs: LFT
Dose/Route/Frequency: 1000 mg,
PO, Q8h
How does it work? unknown action for pain - possibly
increases body’s pain threshold by inhibiting the
formation of prostaglandins
Teaching: carefully monitor all medicines administered and
total up the amount of acetaminophen administered in one
day. Do not exceed 4 grams per day.
Time: PRN
Last Dose Given:
10/17 @ 1032
Recommended/Usual Dose/Max
Dose: 650 mg Q6H.
Not to exceed 4gm per day.
Adverse Effects: no serious s/e, mild GI upset
Black Box Warning: risk of acute hepatic injury resulting
in organ failure and death. Safe dose not to exceed 4gm
per day.
LAC School of Nursing
NURSING CARE PLAN
N233 L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Medication: vancocin
Classification: bactericidal glycopeptide antibiotic
Generic Name: vancomycin
Indication: infection of left foot
Dose/Route/Frequency: 1,000mg,
200 mL/120 min, IVPB, Q12h
How does it work? Produces bactericidal effects by
inhibiting bacterial cell wall synthesis, and may alter cell
membrane permeability and RNA synthesis.
Due on the 6th week of each MedSurg rotation
Assessment: monitor edema, BP, GI symptoms, skin
assessment, and changes in stool.
Labs: electrolytes, trough
Time: 0800, 2000
Last Dose Given: 10/17 @ 1741
Teaching: report symptoms of C-DIFF such as
watery/bloody stools, stomach cramps, fever, for up to 2
months after stopping treatment.
Adverse Effects: nausea, abdominal pain, hypokalemia.
Vomiting, diarrhea, hypotension, peripheral edema
Recommended/Usual Dose/Max
Dose:
Black Box Warning:
Medication: dilaudid
Generic Name: hydromorphone
Classification: Opioid analgesic
Indication: Severe pain, breakthrough pain unrelieved by
non-opioids and oral opiods (if ordered) (5-10 pain)
Dose/Route/Frequency: 0.2 mg =0.2
mL IVP, PRN
How does it work? Binds with opioid receptors in the CNS
and alters perception of pain
metabolized by liver, excreted by kidneys.
Time: PRN
Onset/Peak/Duration: 5 mins/10-20 mins/3-4hr
Adverse Effects: somnolence, s/s of respiratory
depression
Last Dose Given: 10/17 @ 1741
Recommended/Usual Dose/Max
Dose: dosing dependent on opioid
tolerance of patient. Start with 0.10.2 mg IV, over 2-3 minutes, Q3H as
needed.
Black Box Warning: life-threatening respiratory
depression
Assessment: HR BP Resp hold for RR less than 10.
Other: GI, bowel sounds.
Labs:
Teaching: Emergency overdose treatment is Naloxone
LAC School of Nursing
NURSING CARE PLAN
N233 L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Due on the 6th week of each MedSurg rotation
Medication: Oxycontin
Classification: full opioid agonist
Assessment: HR BP Resp hold for RR less than 10
Generic Name: oxycodone
Indication: As needed for pain 5-7 out of 10 uncontrolled
by tylenol.
Other: GI, bowel sounds.
Dose/Route/Frequency: 5 mg, PO,
Q4h PRN,
Labs:
How does it work? Binds with opioid receptors in the CNS
and alters perception of pain
Teaching: Emergency overdose treatment is Naloxone
Time: PRN q4h
Last Dose Given: no previous dose
charted
Onset/Peak/Duration:
Adverse Effects: somnolence, s/s of respiratory
depression
Recommended/Usual Dose/Max
Dose:
Black Box Warning: life-threatening respiratory
depression
Medication: Oxycontin
Classification: full opioid agonist
Assessment: HR BP Resp hold for RR less than 10
Generic Name: oxycodone
Indication: As needed for pain 8-10
Other: GI, bowel sounds.
Dose/Route/Frequency: 10 mg, PO,
Q4h PRN,
How does it work? Binds with opioid receptors in the CNS Labs:
and alters perception of pain
Teaching: Emergency overdose treatment is Naloxone
Onset/Peak/Duration:
Adverse Effects: somnolence, s/s of respiratory
depression
Time: PRN q4h
Last Dose Given: 10/18 @ 0704
Recommended/Usual Dose/Max
Dose:
Black Box Warning: life-threatening respiratory
depression
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Date of Assessment:
Vital Signs: BP
T
P
R
O2Sat ______ Pain Level 8/10
Circle Priority System
Neurological:
Potential Problem: Peripheral neuropathy  prolonged compression of nerves due to lower leg swelling
to compromised blood flow can contribute to peripheral neuropathy. Peripheral neuropathy can impact the
patient’s ability to perceive sensations and may contribute to difficulties with ambulation.
Cardiovascular: cardiogenic shock
Potential Problem: Septic Emboli  Osteomyelitis, especially if caused by bacteria like staphylococcus
aureus, can lead to the formation of septic emboli. These emboli can travel through the bloodstream to
other parts of the body, including the heart. If septic emboli reach the coronary arteries, they can
potentially cause blockages, leading to a myocardial infarction
Respiratory: no respiratory symptoms, respirations unlabored and regular, on RA at 98%. All lobe breath
sounds clear
Potential Problem: pulmonary edema
Gastrointestinal: no GI symptoms, no eating difficulties, good appetite, no nutritional risk factors,
abdomen obese rounded, soft and nontender. Last BM was on admission day. All bowel sounds present
on all quadrants
Potential Problem: gastrointestinal bleeding  patients with a history of HTN and AFib may be on
anticoagulant and increase their chances of bleeding or abdominal cramps with the iron supplements he is
taking
Genitourinary: no symptoms, voiding with no difficulties
kidney failure
Potential Problem: kidney failure
Integumentary: skin color usual for race, skin temperature warm, skin turgor is elastic with instant recoil,
skin moisture is dry, skin integrity assessed pressure areas and localized abnormalities (bilateral lower leg
welling with 2+ pitting edema and left foot infection covered in gauze). Mucous membrane pink and
moist.
Potential Problem; necrosis on left foot d/t decrease perfusion to lower extremity and edema
Musculoskeletal: bilateral upper extremities full strength, bilateral lower extremities move against some
resistance. Lower extremity unequal, right is greater than left. Unable to access gait, patient uses a
wheelchair
Potential Problem: osteomyelitis infection of the bone  amputation
Predominant stressors (intra-, inter-, extra personal):
Intrapersonal: Patient is not taking his diagnosis well, doctors said that they recommend an amputation
but patient does not accept it. He was anxious during my interactions with him and was in a hurry trying
to get discharged from the hospital.
Interpersonal: Patient said he has friends however is unable to see anyone since he is in pain and unable to
walk. He has one son who has 2 kids; however, patient says he gets sad that he does not get to see them
often. Divorced many years ago and says life is very lonely.
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Extra personal: Patient is retired, living in Sylmar and is having his construction company ran by his son,
has no worries about money.
Variables :( physiological, psychological, spiritual, sociocultural, developmental):
Spiritual: patient does not believe in any religion, says he used to when he was young but as he aged he
realized it was all about money.
Physiological: Patient is in a lot of pain and has a decrease in mobility due to his left foot infection and
lower extremity swelling.
Psychological: patient does not accept his diagnosis or the treatment plan that the doctors spoke with him
about in regards to an amputation.
Sociocultural: patient is retired and has no issues with money since his company is still being ran by his
son.
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
NURSING CARE PLAN (Physiological Problem)
ASSESSMENT
SUBJECTIVE:
pain 10/10
asking for pain medication
ANALYSIS
PROBLEM DUE TO
Impaired skin integrity
related to decreased mobility,
bilateral leg swelling, and
MRSA infected osteomyelitis
of the left foot.
PLANNING
Desired Outcome:
By the end of the shift patient
will demonstrate improved
skin integrity, as evidenced
by the absence of new
breakdown, healing of
existing wounds, and
maintenance of the intact skin
in high-risk areas.
2-PRIORITY
INDEPENDENT
INTERVENTIONS
(with rationales):
OBJECTIVE:
open wound on the patients
left foot
unable to put his weight on
the left foot and having to use
the wheelchair (he did not
need a wheelchair prior to
this admission
bilateral edema on lower
extremities
1. Hygiene and skin care
in order to maintain
the area clean and
free of more bacteria
coming in
2. Implementing
position changing
q2h and alternating
pressure points,
utilizing pressure
relieving devices
such as heel
protectors and
cushions in order to
prevent further skin
breakdown
IMPLEMENTATION
EVALUATION
1. wound care was
Outcome: Patients left foot
provided for the
skin integrity was evaluated
patient the morning
and showed no sign of further
of my shift and was
breakdown, patient remained
well covered in
free of fever, and was able to
wound care dressing, change positions.
when looking at the
wound and
comparing the
charting there was no
new breakdown
noticed.
2. Patient allowed me to
help change his
position in bed and I
managed to add some
pillows to help
relieve some of the
Revised Outcome if not Met:
pressure he was
putting on the heel of
his foot.
3. Reported to his nurse
the pain he was
feeling and she
administered the pain
medications that he
was ordered by the
doctor as well as a
prescription of
antibiotics he was
given so he can pick
up after being
discharged
4. No PT came in
during shift however
patient asked me to
notify the nurse if
that is something she
can do or him so he
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
2-PRIORITY
COLLABORATIVE
INTERVENTIONS
(with rationales):
can gain more
independence on his
wheelchair
1. Administering
antibiotics and pain
medication in order
to help fight off the
infection and allow
patient to be free of
pain to increase
comfort and mobility
2. Physical therapist
being brought in in
order to help get that
mobility going and
getting
recommendations to
improve his strength
and prevent further
complications
NURSING CARE PLAN (Psychosocial Problem)
ASSESSMENT
SUBJECTIVE:
Verbalized feeling lonely
since he is not married and
does not get to see his grand
kids often.
Retired
Angry that he cannot walk
and is using a wheelchair
ANALYSIS
PROBLEM DUE TO
Anxiety related to chronic
health conditions and
impaired mobility
PLANNING
Desired Outcome:
By the end of the shift, the
patient will demonstrate a
reduction in anxiety
symptoms, express an
improved understanding of
their chronic health
conditions, and actively
engage in at least one
coping strategy
IMPLEMENTATION
1. engage in active
listening during
patient interactions,
allowing the patient
to express their
concerns and feelings
2. Conduct a
collaborative
discussion with the
patient to identify
specific aspects of
their health and
mobility that
EVALUATION
Outcome:
After speaking with the
patient and allowing him to
express how he was feeling
the patient seems a lot more
nicer and patient. Anxiety
level went down and he
verbalized how thankful he
was and even gave me a hug
when he was discharged.
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
2-PRIORITY
INDEPENDENT
INTERVENTIONS
(with rationales):
OBJECTIVE:
Being mean to me when I first
met him and talking about
how the doctors don’t know
what they’re doing.
Did not want me to leave
Felt better after letting me
interview him and hearing out
everything he had to say and
all his feelings
1. Therapeutic
communication in
order to establish a
therapeutic nurseclient relationship
through effective
communication can
help alleviate
anxiety, provide
emotional support,
and enhance the
clients sense of
control.
2. Collaborative goal
setting involving the
patient in setting
realistic and
achievable goals
empowers them,
promotes a sense of
control, and fosters
motivation for selfcare.
2-PRIORITY
COLLABORATIVE
INTERVENTIONS
(with rationales):
1. Psychosocial support
team collaboration- a
collaborative effort
with mental health
professionals
can
contribute to anxiety
3. Collaborate with the
hospital’s mental
health or psychology
department to
involve a mental
health professional in
the patients care.
Revised Outcome if not Met:
4. Request a
consultation with
physical and
occupational
therapists to assess
the patients mobility
and functional status
(informed the nurse
the patient wanted to
look into physical
therapy)
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
provide specialized
support to address the
patients anxiety and
emotional well being.
2. Physical and
occupational therapy
consultationCollaborating with
physical and
occupational
therapists can address
the patient's impaired
mobility and
contribute to
enhancing their
overall quality of life
3. Multidisciplinary
care conference Bringing together
members of the
healthcare team to
discuss the patient's
care
comprehensively
allows for a holistic
approach and ensures
that all aspects of the
patient's well-being
are considered.
4.
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
NURSING CARE PLAN (Collaborative Problem)
ASSESSMENT
SUBJECTIVE:
ANALYSIS
PROBLEM DUE TO
Pain in lower extremities
Use of a wheelchair
The patient presents with
impaired mobility due to
bilateral leg swelling,
osteomyelitis, and chronic
health conditions, requiring
collaborative interventions to
improve mobility and
enhance rehabilitation
prospects
OBJECTIVE:
Swelling on lower
extremities
PLANNING
Desired Outcome:
By the end of shift the patient
will demonstrate improved
mobility and perform a
specific functional task
3-PRIORITY INTERVENTIONS
(with rationales):
1. Collaborate with
physical/occupational
therapists and the
health care team to
create a targeted
rehabilitation plan
focusing on
enhancing mobility
and functional
independence
2. Develop a specific
goal achievable
within the shift that
aligns with the
overall rehabilitation
plan
IMPLEMENTATION
1. Physical therapy
collaboration to
initiate a structured
mobility program,
focusing on exercises
tailored to the
patients’ capabilities
and limitations
EVALUATION
Outcome:
Patient was able to ambulate
from his bed to his wheelchair
and into the restroom during
shift, also allowing me to help
position his legs differently to
relieve some pressure from
the heel. He was also given a
boot that may help him with
ambulation and keeping off
some weight from affected
foot.
2. Assistive devicecollaborate with
occupational
therapists and
recommend
Revised Outcome if not Met:
appropriate assistive
devices that
facilitates safe
mobility and
independence
3. Informed the nurse of
patients pain and he
was administered his
PRN pain medication
and increased his
level of comfort
which led him to let
me change his leg
position in the bed qa
LAC School of Nursing
N233L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
3. Explain to patient the
importance
of
medication
compliance
to
decrease the level of
pain and help patient
be more comfortable
with mobility and
tolerating better
LAC School of Nursing
N233 L - Intermediate Medical/Surgical & Psychiatric Nursing Clinical – SPRING 2023
Potential Complications
List 3 Potential Complications
Rank order the priority of complications identified.
1. Cardiogenic shock
2. Septic emboli
3. Necrosis of the left foot