Sacrum care plan 
School of Nursing Care Plan
Student’s Name: Joie Ferreiro________________________________ Date: 9/5/14
Client’s Initials: R.S. Admission Date: 7/30/14 Age: 96 Sex: f___ Race: __w____ Religion: Jewish
Allergies: Phenobarbital
Diet: NPO Activity: Bed rest
Admitting Medical Diagnosis (es):
Sacral decubitus ulcer, polymicrobic sacral osteomyelitis
Past Medical History (including past surgical history): Illnesses include:
1) Renal insufficiency
2) Anemia
3) hyperthyroidism
4) CHF
5) Dementia
6) hypertension
7) Atrial fib
8) MI
9) atherosclerotic heart dysfunction
10) diastolic heart dysfunction
11) remote history of subdural hematoma
12) Hyperlipidemia
13) osteoarthritis
14) Neuropathy Surgeries include, but no dates are given via the patient:
1) left hip replacement
2) Total abdominal hysterectomy & oophorectomy
3) Right hip replacement.
Present Surgical Procedures (including of Illness: Peg tube insertion at Aventura Hospital, due to nutritional deficiency.
Client’s Understanding of Illness: Client suffers from dementia, and is relatively confused all the time. Understanding of the illness would just lead to more confusion.
History of Present Illness: Patient transferred from Aventura Hospital on 7/30/14. She is a very pleasant 96 year old woman, although she is not completely oriented. She is awake and alert, but believes she is at home or at a hotel. Patient has a larger sacral wound, measuring 3cm long, 2cm wide and 0.1cm deep. It is a stage IV pressure ulcer. Patient is also on a peg tube for feeding and medications, she is nutritionally deficient and has a very poor appetite. Vascular dementia significant with encephalopathy adds to her confusion and disorientation as to locations. Patient also suffers from polymicrobic sacral osteomyelitis, which is where the pressure ulcer is located. On 7/30/14 a wound vac was placed on the wound at Aventura Hospital, 8/5/14, biopsy was performed of sacrum with a debridement.
Student’s Name: Joie Ferreiro________________________________ Date: 9/5/14
Client’s Initials: R.S. Admission Date: 7/30/14 Age: 96 Sex: f___ Race: __w____ Religion: Jewish
Allergies: Phenobarbital
Diet: NPO Activity: Bed rest
Admitting Medical Diagnosis (es):
Sacral decubitus ulcer, polymicrobic sacral osteomyelitis
Past Medical History (including past surgical history): Illnesses include:
1) Renal insufficiency
2) Anemia
3) hyperthyroidism
4) CHF
5) Dementia
6) hypertension
7) Atrial fib
8) MI
9) atherosclerotic heart dysfunction
10) diastolic heart dysfunction
11) remote history of subdural hematoma
12) Hyperlipidemia
13) osteoarthritis
14) Neuropathy Surgeries include, but no dates are given via the patient:
1) left hip replacement
2) Total abdominal hysterectomy & oophorectomy
3) Right hip replacement.
Present Surgical Procedures (including of Illness: Peg tube insertion at Aventura Hospital, due to nutritional deficiency.
Client’s Understanding of Illness: Client suffers from dementia, and is relatively confused all the time. Understanding of the illness would just lead to more confusion.
History of Present Illness: Patient transferred from Aventura Hospital on 7/30/14. She is a very pleasant 96 year old woman, although she is not completely oriented. She is awake and alert, but believes she is at home or at a hotel. Patient has a larger sacral wound, measuring 3cm long, 2cm wide and 0.1cm deep. It is a stage IV pressure ulcer. Patient is also on a peg tube for feeding and medications, she is nutritionally deficient and has a very poor appetite. Vascular dementia significant with encephalopathy adds to her confusion and disorientation as to locations. Patient also suffers from polymicrobic sacral osteomyelitis, which is where the pressure ulcer is located. On 7/30/14 a wound vac was placed on the wound at Aventura Hospital, 8/5/14, biopsy was performed of sacrum with a debridement.