Plan of care for wound healing

Client initials: J.S.
Age/DOB: 28
Allergies are not included.
BSA/BMI is not available.
Code Status: Not mentioned

Date of Admission: 7/3
Date of Care: 7/3, 7/10
Admitting Diagnosis: The grinder's right arm is lacerated.
Planned Treatments/Procedures: Initial wound care, Tdap booster,
cephalexin for infection, and ceftriaxone I.M. for infection

The Nursing and HCP Collaborative Plan for Care should include a list of priority client-specific information, nursing actions, and provider orders.
Priority information: The client has a foreign body in his arm. Initial treatment comprises wound cleaning.
Nursing Actions: Check the wound for an available infection, administer prescribed medications, and provide advice on how to care for the wound.
Provider Orders: X-ray of the arm, Tdap booster, wound irrigation, suture placement, and antibiotics for infection care.
Cultural/Spiritual:
Not identified.
Neurological/Cognition/Coping/Adaptation/Function:
The client is alert, oriented, and has clear speech (x4).
Nutrition/Elimination:
No problem was noted.
Fluid/Electrolytes/Acid-Base:
Not mentioned
Gas Exchange/Perfusion:
The history of vaping causes continuous breathing, but it also causes
expiratory wheezes.
Glucose Regulation:
Not applicable.

Health Promotion/Development:
The importance of wound care and suture removal follow-ups should be
emphasized.
Infection/Immunity/Inflammation:
Continuous wound care for infection prevention.
Mobility:
The patient ambulates with a continuous gait.
Pain/Comfort/Tissue Integrity:
The client is confirmed with a 5/10. Pain management and checking for
wound integrity are essential.
Safety:
Enable the client to gain insight into wound instructions to prevent
infection.
The client has a confirmed history of asthma.

START of Shift (CJSimTM) Priorities (Complete after receiving the report and reviewing the EHR connected to phase 1 of the Question 1 section.)
Recognize and analyze cues. Prioritize Hypotheses Generate solutions and take

action. Evaluate Outcomes

Priority Assessments/Cues Priority Hypotheses for Nursing

Care Priority Interventions/Actions Priority Teaching and Discharge

Needs

1. A wound assessment
reveals bleeding and a foreign
body in the arm.

1. There is a risk of infection and
poor pain management.

1. Irrigate the wound and
take away the foreign
body.
2. Give Tdap boosters
and prescribed
antibiotics.

1. Ensure that the bleeding is
significantly under control and that
there are no signs of infection in
the wound.

Priority Laboratory Tests and
Diagnostic Cues

Priority Actual and potential
complications Priority Medications Priority collaborative actions

1. X-ray the arm to find foreign
bodies.

1. Asthma causes infections and
poor wound healing.

1. For infection management, use
cephalexin and ceftriaxone.

1. Team up with a healthcare
provider for a wound check and
follow-up treatment.

Vital Signs and Pertinent Lab Trends

The shift analysis (CJSim) (phase 1, question 1) has begun. The shift (CJSim) analysis has reached its conclusion (phase 3,

question 3, section 3).

The Mid-Shift Purposeful Clinical Judgment (CJSim) is complete after

reviewing the EHR/Question 2 section.

Complete the clinical debriefing by answering these questions after

providing complete care for the client.

2

Answer these questions about today's client:
1. Recognize cues—explain any assessment changes since the start of the
shift. 
Initial Assessment (7/3 at 1630):
The client presented with a laceration on the right arm, holding pressure
to control bleeding.
Ambulated with a steady gait.
Reported 5/10 sharp stabbing pain.
Unsure of the last tetanus shot.
2. Analyze cues: How significant are the changes?
The changes are critical because, if not effectively treated, they can lead
to more severe systemic infections.
3. Prioritize hypotheses: What could be causing the changes?
A foreign body could potentially cause an infection.
4. Generate solutions: What can or should you do about these changes?
Irrigate the wound and take away the foreign body.
5. Take Action—What steps did I take to address the issue? What do I do
about it?
Administer the Tdap booster as prescribed.
6. Evaluate outco