1. Patient Profile
Group 5

2. Sarah Gomez Age: 8 Ht: 50inches Wt: 55lbs Ethnicity: Hispanic
Admitting Diagnosis:
Traumatic Injury: Spiral L Forearm fracture, bruised spleen
Medical History:
This is Sarah’s second time being admitted in the hospital for traumatic injuries.

3. Environment Socioeconomic: Low income
Dwelling: Apartment in the inner city

4. Family Life
Sarah lives with her mother, Linda, who recently had another baby. They also live with her mother’s boyfriend. The boyfriend has a history of substance abuse and has been arrested for violence.
Sarah’s secondary caretaker is her grandma who lives just up the street.

5. Care Plan Priority Nursing Diagnosis Top Nursing Diagnosis
Activity intolerance
Bathing self-care deficit
Impaired physical mobility
Priority Nursing Diagnosis
Bathing self-care deficit
Patient Outcome/Goal
Patient should be able to shower with assistance of a nurse to keep cast dry. Patient should also be able to use bathroom with assistance from parent or nurse due to use of IVs and as precaution to any fall or confusion due to use of pain medication.

6. Current Orders Order Rational for Order Shower with Assistance
Not bed bound. Currently on pain medication for management of pain from spleen so potential drowsiness. Arm needs to be wrapped prior to shower and should not get wet or be used during the duration of the shower. Assistance with washing, balance if needed, and keeping arm out of water.
Diet: No restrictions
No vomiting, allergies, or reasons for any diet restrictions.
Normal mealtimes are to be kept with the addition to a morning and evening snack if desired.
Bathroom: Able to go in room attached bathroom with assistance as needed
Patient is on a portable IV unit that can be moved with assistance of family member or nurse. Should not be attempted alone as to prevent any pulling or tangling of the lines.
Bedside commode at night as needed
As a convince, if patient is too fatigued or in pain to go to the bathroom she can use the bedside commode.

7. Nursing Interventions
Only use necessary assistance to promote activity in patient
Assess patient pain and administer pain relief as needed prior to hygiene care
During shower be careful to respect patient and consider and be alert for any discomfort, anxiety or fear.
Incorporate family/caretakers in assistance needs and educate on necessary techniques.
Rationale
Incorporating normal activity and exercise can better all aspects of the patient’s rehabilitation. (Potter & Perry (P&P) p. 746)
Administering medication… before providing hygiene intervention helps maintain pt comfort during hygiene care. (P&P p. 782)
Hygiene care can invoke stress or anxiety on patient (P&P p. 782)
Family often need guidance in adapting techniques due to patient’s limitation. (P&P p. 782)

8. Outcome Met: Goals were met
Evaluation of Patient
Outcome Met: Goals were met
Patient was able to shower successfully with help from the nurse and reported a minimal pain increase from activity due to pain med administration prior to the shower.
Cast was kept dry due to a plastic wrap and assistance from the nurse.
Sarah has been able to use the bathroom during the day with the help of mom and grandma with the portable IV unit.
Sarah has not yet used the bedside commode as she has been able to go to the bathroom with her assistance.

9. Redness, irritation and bleeding from scratches
Day #2
Today you are assigned to Sarah again and she has been complaining of itching under her cast. She has been using a pencil all night to reach down in her cast and scratch.
During your assessment, you notice irritation, redness and bleeding on her skin where the cast ends and that there is an odor coming from it.
What is your priority nursing diagnosis?
Write a care plan for this diagnosis.
Redness, irritation and bleeding from scratches