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Brandi Anastacio, N360 Concept Map, 03/28/2014 Prof.


Infection: At site: pain on palpation, erythema, purulent drainage, swelling Labs: Neutrophils: 72.3 Meds: Zosyn IVPB, Bacitracin prior to surgery

Decreased Cardiac Output Hx: CVA, MI, Hypertension and Diabetes Assessment: Weak bilateral pulses, stronger in upper extremities. Doppler needed to assess lower extremities. Heart sounds auscultated with S1S2, pacemaker/ICD noted, Client states I have a super pace maker! Lungs sounds clear bilaterally in all lobes, with diminished breaths sounds in lower lobes. Client denies chest pain and states only SOB upon ambulation. Tx: Cardiac Diet, Monitor I/O and Daily Weight Meds: Carvedilol, Docusate, Aspirin, Furosemide, Lisinopril, Nitroglycerin, Potassium Chloride

Ineffective Health Maintenance Labs: HbA1C: 15.2 Avg glucose: 390, BUN:25, GFR: 43, Hct: 27.7%, Hgb 8.2 BMI: 66.1 Tx: Cardiac/Carb Diet, Glucose Checks AC/HS, Insulin: Novolog (with sliding scale coverage) and Levamir

Impaired Physical Mobility: Right Foot Wound BMI: 66.1 Verbalizes SOB during AMB and impaired sensation in lower extremities Devices: FWW, WC

Chief Medical Dx: Cellulitis with Gangrene to the Right Foot Priority Assessments: Pain, Neurovascular, Integumentary (Wound), Mobility, Psychosocial, Cardiac, Respiratory

Anxiety Right BKA surgery scheduled Client verbalizes concerns regarding mobilization, family support and rehab Therapeutic communication initiated regarding concerns: social worker, PT and OT consult ordered Family (Niece) at bedside during care, assisting client with coping by taking pictures of clients right leg and walking in the room Meds: Melatonin PRN for sleep

Impaired Tissue Integrity: Right foot wound: two necrotic areas, on great toe and lateral surface Wound Care: Apply Silver Sulfadiazine and cover with dry gauze Surgery planned for right BKA

Ineffective Tissue Perfusion: CMS: BLE cool, hairless, shiny, pale and dorsal pedal pulses bilaterally equal, but very weak, assessed with Doppler. Fully bears weight on left leg, weaker on right. Client states sensation felt to both legs, but numbness comes and goes. Angiogram to right leg {Results pending} Meds: Atorvastatin, Clopidogrel, Heparin and Aspirin Tx: Maintain O2Sat >92% (NC O2 PRN), AROM and AMB with assist

Acute Pain Client states pain 6/10 on palpation of right lower extremity Pain also related to multiple blood draws and needle sticks due to the difficulty of vascular access Managed with Tylenol and positioning dependently at side of bed PICC inserted for med admin and blood draws