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Answer :
The NDX that should be given top priority for this case study is “Infection.” The problem statement (PES) is as follows: Problem: Infection Etiology: Open wound in the right thumb, pretibial area of both legs and infected wound on the right buttock Secondary Effects: Increase in WBC and lactate levels. Nursing interventions that should be taken in this case are as follows:Assessments:1. Monitor vital signs and provide immediate interventions for vital sign changes.
2. Monitor the patient’s temperature and intervene if the temperature is not within normal limits.
3. Monitor the patient’s urine output and intervene if urine output is less than 30 mL/hr.
4. Monitor the patient’s white blood cell count and intervene if the count is above the normal limit.
5. Assess for signs of infection and intervene if present
6. Assess the patient’s pain level and intervene as appropriate.
7. Assess the patient’s skin integrity and intervene if any breaks in skin are noted.
Do: 1. Administer antibiotics as ordered by the physician.
2. Administer medications to manage pain.
3. Administer medications to manage anxiety.
4. Administer medication to control seizures.
Teach: 1. Teach the patient about hand hygiene.
2. Teach the patient about the importance of wound care.
3. Teach the patient about medication management.
Scientific rationale for the interventions taken:
1. Antibiotics are administered to manage the infection.
2. Medications are administered to manage pain, anxiety, and seizures.
3. Hand hygiene is taught to prevent the spread of infection.
4. Wound care is taught to promote healing and prevent the spread of infection.
5. Medication management is taught to prevent adverse effects and promote proper healing.
Evaluation of the outcome is as follows:
1. The patient’s temperature is within normal limits.
2. The patient’s urine output is greater than 30 mL/hr.
3. The patient’s white blood cell count is within normal limits.
4. The patient’s pain level is controlled.
5. The patient’s anxiety is managed.
6. The patient’s seizures are controlled.
7. The patient is educated about hand hygiene, wound care, and medication management.
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