Cam Newton
Background
28 years old male
5’10”
160lbs
Asian-Indian
IT Consultant
Married with 3 children
Live in 2 story house
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
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
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.
Patient Goal
No infection by proof of absence of redness/swelling of abrasions, WBC withinnormal range by end of shift.
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 patientcomfortable. Keeping the dressing(s) dry will prevent bacterial growth.
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 hisfemur was delayed. He is not POD#2. He is still on bedrest and has a CPMmachine on his left leg. Physical Therapy will start working with himtomorrow.
During your assessment you ask Cam when his last bowel movement was andhe 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.