Identify: Three (3) priority nursing assessments you would conduct to determine the nursing care John requires. At the time of the injury minimal first aid was applied, leading to the bacterial infection and cellulitis of the lower leg.
Identify: Three (3) priority nursing assessments you would conduct to determine the nursing care John requires. At the time of the injury minimal first aid was applied, leading to the bacterial infection and cellulitis of the lower leg.
John, a 41 year old male, has a severe gram negative bacterial infection to a wound on his left foot.
Ten (10) days ago John cut his foot on an oyster shell whilst out fishing. At the time of the injury minimal first aid was applied, leading to the bacterial infection and cellulitis of the lower leg. John states pain has been managed with OTC “Nurofen and Paracetamol” as recommended by his chemist.
John was admitted to hospital five (5) days ago following unsuccessful oral antibiotics from the GP. He has commenced intravenous antibiotics which the wound is responding well to.
John has a medical history of chronic anxiety which is managed with a mental health plan and diazepam as required.
You are commencing the morning shift on day five (5) of John’s admission, the following are the last set of observations; please refer to the attached bedside charts for more information:
Medical orders
· Foot elevation
· Cellulitis marking
· Daily wound dressings
· Pain management
· Eat and drink as tolerated
Medications orders
· intravenous gentamicin 300mg TDS
· oral paracetamol 1g 4-6 hourly
· oral ibuprofen 400mg TDS
· oral diazepam 5-10mg PRN
Other useful information
Vital Signs (day 5 0600)
Sedation Alert
Blood Pressure
172/92 mmHg
Heart Rate 108 bpm regular
Oxygen saturation100% on RA
Respiratory rate 20 bpm
Pain score 3/10 discomfort
Temperature 36.5oC
Output average 30mls p/hr
Pathology(on admission
)WBC18.0 x 109/L (4.0-11.0)
urea7.8mmol/L (3.0-8.0
serum creatinine 96μmol/L (60-100)
eGFR 75mL/min/1.73 m2 (90-120)
Urinalysis (day 5 0600)
pH 7.0
Specific Gravity 1.005
Protein ++
Glucose nil
Nitrite nil
Leukocyte nil
Blood +
Colour dark yellowish/brown
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