Pain Rated 10/10 located on his back from spinal osteomyelitis, and sacral/coccyx area from wound -Agitated

-Facial grimace with activity patient had a fever, chills,a positive sputum culture, with productive cough,fatigued, and the spinal osteomyelitis. Patient has a bed sore as well on his sacral/coccyx area appears to be red in color, no blanching, no discharge. CARE Plan: Nursing DX Ineffective renal tissue perfusion R/T renal insufficiency AEB elevation in BUN/Creatinine ratio Outcomes -Client will maintain optimal tissue perfusion to vital organs ensured by presence of strong peripheral pulses, absence of respiratory distress, absence of chest pain, adequate urine output while on unit. -Client will remain free of peripheral/pulmonary edema while in hospital -Client will verbalize knowledge of treatment regiment, including medications and their actions and possible side effects while in hospital. Interventions -Monitor strict I&O s -Monitor labs, notify M.D. of any changes-Assess for signs of decreased tissue perfusion i.e. weak/absent pulses, edema, cool extremities, mottling, prolonged capillary refill, tachycardia, hypotension, and tachypnea. Evaluation -B/P remained within acceptable parameters: 126/79-128/80 -Pulses present in all locations, no edema found, lungs clear to auscultation, capillary refill <2seconds, respirations between 18-20 breaths per minute, o2 saturation-94%-96% room air. -Client able to recognize medications administered and verbalizes actions/side effects. Nursing Dx Impaired tissue integrity R/T pressure, altered circulation AEB damaged integumentary tissue to sacral/coccyx area Outcomes -Client will report any altered sensation/pain at sight of tissue impairment while on unit -Client will demonstrate understanding of plan to heal tissue/prevent injury by discharge -Client will describe measures to protect and heal the tissue, including would care prior to discharge Interventions -Monitor status of skin around wound, assess blanching. Monitor client s skin care practices, noting type of soap used, temperature of water, and frequency of skin cleaning -Don t position client on site of impaired tissue integrity -Assess nutritional status -Reposition client every 2 hours Evaluation -Client able to readjust position independently, and was doing so as necessary in 2 hour increments -Client consuming 100% of meals offered -Sacral/Coccyx area site inspected, redness present, no swelling, abrasion like in appearance, no discharge noted. Nursing Dx Risk for further infection R/T inadequate primary defenses (broken skin), tissue destruction, and spinal osteomyelitis. Outcomes

-Client WBC will remain within acceptable parameters (4.3-12.0) while in hospital. -Temperature will remain below 100.0F while in hospital -Client will be free of symptoms of infection (fever, redness, pus discharge, and swelling) while in hospital -Client will demonstrate appropriate care of infection prone site 3 days before discharge by washing hands, and performing appropriate wound care technique. Interventions -Wash hands before and after each patient care activity; ensure aseptic handling of all IV lines, ensure appropriate wound care technique -Ensure appropriate hygienic care with hand washing; bathing, hair and nail, and perineal care performed by nurse or client -Observe and report signs of infection i.e. redness, swelling, discharge, elevated temperatures. -Teach client symptoms of infection that should be promptly reported to primary medical provider Evaluation -WBC levels consistently within parameter (4.3-12.0): 4.70, 5.60, and 5.40 -Oral temperature measured: 98.6F, 98.0F, no swelling, no discharge, redness present with complaints of pain. -Client able to explain signs of infection by stating if finds swelling, discharge, develops fever, excess redness he will report to care provider. -Hand washing performed before/after all patient care/interaction; aseptic technique performed with IV line/picc; wound care instructions followed. -Client reports fatigue. Nursing DX Chronic pain R/T Spinal Osteomyelitis AEB patient stating his pain is 10/10 on a 1 to 10 scale. Outcomes -Client will use pain rating scale to identify level of pain intensity to determine comfort/function goal while in hospital -Client will verbalize to staff when pain level reaches 5 on a 1 to 10 scale while in hospital -Client s pain level will not exceed 8 on a 1 to 10 scale while in hospital -Client s pain will be less than 2 within the hour after administration of pain medicine Interventions -Instruct client to notify staff when pain level reaches 5 -Medicate client as soon as reports pain 5/10 -Assess therapeutic effect of medication within 15minutes of administration -Monitor client for any nausea/vomiting side effects Evaluation -Client reported pain reached 10/10 on a 1/10 scale -Pain medication successful in reducing pain level to 2/10 -Client did not have any complaints of nausea/vomiting