Identify: Three (3) priority nursing assessments you would conduct to determine the nursing care John requires.John, a 41 year old male, has a severe gram negative bacterial infection to a wound on his left foot.

Identify: Three (3) priority nursing assessments you would conduct to determine the nursing care John requires.John, a 41 year old male, has a severe gram negative bacterial infection to a wound on his left foot.

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

Task 1

Based on the handover information and in grammatically correct sentences identify:

Three (3) priority nursing assessments you would conduct to determine the nursing care John requires. AND For each assessment you have identified explain:
Why it is necessary for John’s condition and nursing care?
What consequence scan occur if this assessment is not conducted or completed accurately?

(250 words) approx. 83 words for each assessment

These are ideas for nursing assessments

Wound assessment

Urine Output assessment

Urine analysis … ph level and specific gravity

IV Cannula assessment .. (Please see below) and rewrite if necessary, I will reference this .. please edit

Explanation & Answer

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