- Acute Pain related to Skin infection and abscess formation as evidenced by reports intensity using a standardized pain scale and skin tender to touch, Purulent drainage
- Hyperthermia related to Infection as evidenced by Tachycardia and Fever
- Impaired Skin Integrity related to broken, traumatized skin as evidenced by Abscess formation and altered turgor
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to Skin infection and abscess formation as evidenced by reports intensity using a standardized pain scale and skin tender to touch, Purulent drainage | Patient will implement two strategies to reduce pain. Patient will report a decrease in pain using a pain scale. | 1. Administer medications as ordered. Medications like antibiotics and analgesics can help clear out infections, promote wound healing, and relieve pain. 2. Encourage wound care. Proper wound care is essential in preventing the spread of infection and further damage to the tissues. 3. Encourage nonpharmacologic pain approaches. Nonpharmacologic pain interventions are known to help improve pain symptoms without the side effects of medications. These include cool compresses and elevation of the extremity. 4. Avoid touching the area. Instruct the patient not to further pick or touch the skin beyond what is required for cleaning as this may further irritate the area and introduce bacteria. | Patient implemented two strategies to reduce pain. Patient reported decreased pain using a pain scale. |
| Subjective data: Verbalizes Increased body temperature. Objective data: -Flushed skin -Skin warm to touch -Tachycardia -Tachypnoea -Fever above 100.4 F (38.0 C) -Diaphoresis | Hyperthermia related to Infection as evidenced by Tachycardia and Fever | Patient will maintain core body temperature within expected limits. Patient will not experience worsening complications of hyperthermia, such as seizures. | 1. Initiate a tepid sponge bath. A tepid sponge bath is an effective cooling intervention that can be delegated to a nursing assistant. 2. Administer appropriate medications as ordered. The administration of IV antibiotics such as vancomycin is given for severe infections that are caused by MRSA infections. Antipyretics can reduce the temperature for comfort. 3. Encourage fluid intake. Increased metabolic rate, diuresis, and hyperthermia can cause loss of body fluids. Fluid replacement is essential to prevent dehydration. 4. Encourage external cooling measures. Cooling measures like a fan or a cooling blanket can reduce the internal body temperature. Ensure not to induce shivering, which causes the opposite effect. | Patient maintained core body temperature within expected limits. Patients worsening complications of hyperthermia, such as seizures are relieved. |
| Subjective data: -Pain -Itching -Numbness to affected and surrounding skin Objective data: -Changes to skin colour -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Skin Integrity related to Broken, traumatized skin as evidenced by Abscess formation and Altered turgor | Patient will regain the integrity of the skin surface. Patient will display healing of the skin as evidenced by reduced erythema, swelling, or drainage. | 1. Keep the wound clean and dry. Keeping the wound and surrounding skin clean and dry will encourage healing and prevent further skin damage. 2. Sanitize linens. Bed linens, towels, and any clothing that came into contact with the broken skin should be sanitized in hot water after use and not reused or shared among other family members. 3. Encourage meticulous wound care. Proper wound care prevents infection and other complications. Always wash hands before performing wound care and after handling soiled bandages. Keep the wound covered so bacteria cannot enter. 4. Prepare for I&D. Incision and drainage may be necessary if an abscess forms to release purulent drainage. 5. Use aseptic techniques. In hospital settings, nurses and healthcare workers must take great care to prevent MRSA infections when patients have IV or urinary catheters, as improper disinfection practices can lead to hospital-acquired MRSA. | Patient regained the integrity of the skin surface. Patient displayed healing of the skin as evidenced by reduced erythema, swelling, or drainage. |