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Avalmoja - FINAL CONCEPT MAP 46
Avalmoja - FINAL CONCEPT MAP 46
4) Infection
WBC 12.45
R foot cellulitis c erythema and edema present
Necrotic tissue to 1st, 3rd and 4th toe to R foot
Piperracillin/Tazobactam (Zosyn)
Vancomycin
Cefepime
1) Oxygenation/Decreased Perfusion
RBC 3.4, Hgb 10, Hct 30
cap refill to all extremities < 3 seconds
History of hypertension
History of aortic stenosis
History of peripheral artery disease (PAD)
Aspirin
Warfarin
Enoxaparin (prophylactic Tx)
Incentive spirometer (10 breaths hourly)
CMS intact for bilateral lower extremities
bilateral dorsalis pedis and posterior tibialis
pulses heard upon auscultation by Doppler
ultrasound
ACE wrap to R lower extremity
Elevation of R lower extremity
Alona K Valmoja
N360 Clinical 4/18/2016
5) Impaired Physical
Mobility
Pain to R lower extremity with
activity and movement
R lower extremity weakness
Fatigue
Use of walker
Fall precautions
Bed at lowest position/bed alarm
Use of bedside commode as
indicated
active and passive ROM exercises
Call light within reach of patient
6) Activity Intolerance
Patient states I feel very tired after
position change from supine to sitting
on side of bed
Weakness/limited mobility to R lower
extremity
Pain to R lower extremity
Patient able to tolerate transfer from
bed to bedside commode, and transfer
from bed to chair
use of walker, assist with ambulation