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N30030 Concept Map
Student Name: Sarah Henderhan Client Initials: G.A.
Date: 10-25-10
Age: 56 Gender: Male
Room: 885
Admit Date: 9-20-10
Code Status: FULL Allergies: NKA Diet: 1800cal ADA diet Activity: Up as tolerated, no
weight bearing on right foot, keep right foot elevated on 2-3pillows. Braden Score: 19
Medications
Piperacillin/Tazobactam sodium (Zosyn) 9g in 240 ml of 0.9% Sodium Chloride at 10ml/hr IV-Antibiotic for skin and suture infections.
Heparin (Heplock) 5,000 units SQ q8h.
-Prevention of thrombus formation.
Gabapentin (Neurontin) 300mg PO once daily.
-Chronic pain (Unlabeled use).
Aspirin (ASA) 80mg PO once daily.
-Blood thinner, and anti-inflammatory.
Lisinopril (Zestril) 10mg PO once daily.
-Lowers blood pressure.
Hydromorphone HCL (Dilaudid) 1mg IV q2h as needed for pain.
-Reduction of pain.
Vancomycin HCL (Vancocin) 1.5g 250ml of NS IV q8h.
-Treatment of infection.
Regular Insulin (Humulin R) 24untis SQ 30min before meals.
-Lowers blood glucose.
Insulin Human Lispro (Humalog) 2-100 units sliding scale SQ AC and HS.
-Lowers blood glucose.
Insulin Human NPH (Humulin N) 18 units SQ two hours before meals.
-Lowers blood glucose.
Mupirocin (Bactroban) 1G topically BID to right foot and second digit.
-Treatment of diabetic foot infection.
IV Sites/Fluids/Rate
1-#24 LAC with continuous Zosyn at 10ml/hr.
2-#22 RFO Heplock.
Assessment Data
Weight: 191lbs, 87kg. T- 97.5 F (oral), P- 60, R- 18, BP- 155/104, Pulse Ox- 96% on room air. Pain 0 on a scale of 0-10. A&O x 3. Responds appropriately to verbal stimuli. Glasses present. Appeared calm and was dressed in a hospital gown. No signs of anxiety Pt. answers questions readily and maintained eye contact. Skin was normal for ethnicity, warm, dry, and intact except fortwo wounds on right foot and second digit. The wound on the anterior portion of the foot was circular in shape, approximately 3cm by 2cm, wound pink, slightly erythemic and moist with a small amount of serosangiunous drainage, no odor noted. Small amount of debrieding noted with drsg. removal. Aquacel and kling applied. The right second digit wound approximately .5 by .5cm. dry diabetic wound, surrounding tissue was white crusted, dressing applied. Pt. has age spotson his arms, chest, and face. Skin turgor present, head was symmetrical, temporal pulse +2. No edema noted. Hair distribution even, thick and beginning to grey. Upper and lower extremities warm. Capillary refill < 2 sec. Nails pink and normal. Mucus membranes pink, moist, and intact with no swallowing difficulties. Oral hygiene poor as evidenced by missing teeth, halitosis, and yellow stained teeth. Speech clear, PERRLA, Respiratory pattern easy and unlabored with symmetrical movement, no cough or sputum present, lungs clear anteriorly and posteriorly all lung fields.
No shortness of breath or dyspnea noted. Apical rate 62 regular rhythm. Abdomen soft, rounded,and non-distended. Denied any pain or discomfort upon palpation. Bowel sounds present times four. Feeds self. Pt. on 1800 cal ADA diet. Pt states “I know I am diabetic but I eat what I want. They don’t feed you enough in here (hospital), you have to eat when you’re diabetic because yoursugar will go down. I probably eat too much.” No BM during shift. Voiding clear, yellow urinewithout difficulty. MAE. Strong, equal hand grasps and leg pushes. Dorsalis pedis and posterior tibial pulse +2 bilaterally. ID band legible, bed in low position, side rails up x2, brakes on, call light within reach.
Primary Nursing Diagnosis
Evaluation
Ineffective peripheral tissue perfusion r/t compromised blood Goal met patient experienced adequate tissue perfusion AEB maintaining capillary refill less than 2 seconds, +2 pedal pulses, skin warm and dry, and decreased pain. G.A. was able tomeet this goal because… Supporting Data
1.) His right leg was elevated throughout the clinical shift. R ationale- Venous blood flow is enhanced in an elevated posit -Zosyn 9g in 240 ml of 0.9% Sodium Chloride at 10ml/hr IV 2.) His extremity was kept warm by blankets throughout the - Bactroban 1G topically BID to right foot and second digit.
day. Rationale- A warm environment promotes vasodilatatio n which promotes tissue perfusion. (Black & Hawks, 2009).
3.) I applied Bactroban 1G topically to right foot and second Short Term Goal
Rationale- Bactroban treats infected skin by inhibiting bacter The patient will have adequate tissue perfusion by discharge ial protein synthesis. (Deglin & Vallerand, 2008).
AEB maintaining capillary refill less than 2 seconds, +2 pedal 4.) The nurse administered Lisinopril 10mg PO once daily, t pulses, skin warm and dry, and decreased pain.
o keep his hypertension under control.
Rationale- Hypertension leads to vasoconstriction which canimpede blood flow. (Black & Hawks, 2009).
Long Term Goal
5.) The nurse administered Insulin NPH 18Units two hours b Patient will demonstrate lifestyle changes to improve circulati efore meals, Insulin Lispro 2-100 Units sliding scale insulin on which includes smoking cessation, exercise, and diabetes a AC and HS, and Regular Insulin 24 Units 30 minutes before nd hypertension control by three months.
Interventions
Rationale- Uncontrolled diabetes can cause vascular damage -Elevate the right extremity while in bed.
which also impedes blood flow. (Black & Hawks, 2009).
Rationale- Venous blood flow is enhanced in an elevated posit Evaluation
Long term goal not met pt. showed no interest in smoking ce -Keep extremities warm by avoiding cold drafts, and use of bl ssation, or beginning an exercise regimen during the clinical shift. I believe that to quit smoking by two months, the patie Rationale- A warm environment promotes vasodilatation whic nt would have to show initiative to quit smoking and engage h promotes tissue perfusion. (Black & Hawks, 2009).
in a healthier lifestyle. Revisions are as follows: -Apply Bactroban 1G topically to right foot and second digit t 1.) Assess pts. desire to stop smoking.
Rationale- Assessment of the desire to quit smoking is the fir Rationale- Bactroban treats infected skin by inhibiting bacteri st step to quitting. (Black & Hawks, 2009).
al protein synthesis. (Deglin & Vallerand, 2008).
2.) Encourage pt. to stop smoking PRN.
Rationale- Quitting smoking now, decreases risks associated Rationale- Smoking causes vasoconstriction which can decrea with smoking.(Black & Hawks, 2009).
se peripheral perfusion. (Black & Hawks, 2009).
3.) Call the physician for an order for Chantix.
-Teach pt. how to inspect the feet and daily foot care; daily.
Rationale- Chantix is a prescription drug to decrease the desi Rationale- Daily foot care reduces tissue damage and helps de re to smoke by preventing the biding of nicotine to receptors.
tect early trauma. (Carpenito-Moyet, 2010).
-Administer Lisinopril 10mg PO once daily.
4.) Personalize a plan to quit smoking once a day.
Rationale- Hypertension leads to vasoconstriction which can i Rationale- Success is more likely if people spend time planni mpede blood flow. (Black & Hawks, 2009).
ng a behavior change. (Black & Hawks, 2009).
-Administer Insulin NPH 18Units two hours before meals, Ins 5.) Teach pt. the benefits of exercise daily.
ulin Lispro 2-100 Units sliding scale insulin AC and HS, and Rationale- benefits of exercise are decreased weight, lower b Regular Insulin 24 Units 30 minutes before meals.
lood pressure, improved mood, decreased stress, and reduces Rationale- Uncontrolled diabetes can cause vascular damage chances of heart disease. (Black & Hawks, 2009).
which also impedes blood flow. (Black & Hawks, 2009).
Nursing Diagnosis #2
Evaluation
Impaired skin integrity r/t delayed wound healing secondary t Goal not met. Patient showed no signs of improved sk in integrity during the clinical shift. Continue plan ofcare and some revisions for the plan of care are as follows: Supporting Data
1.) Prevent injury to healing tissue during cleaning.
Rationale- Normal saline should be the only product u sed to clean the wound. Other products such as iodine and hydrogen peroxide can cause damage to the heali - Bactroban 1G topically BID to right foot and second digit.
ng tissue. (Black & Hawks, 2009).
2.) Keep the surrounding skin dry at all times.
Short Term Goal
Rationale- This protects the surrounding skin from fut The patient will experience improved skin integrity AEB no m ure breakdown. (Black & Hawks, 2009).
anifestations of infection in the wound by discharge.
3.) Facilitate debridement during dressing changes.
Long Term Goal
Rationale- debridement is needed to remove nonviable tissue in the wound. (Black & Hawks, 2009).
The patient will have a smaller wound from baseline within three weeks.
Interventions
Evaluation
-Monitor wound site during dressing changes and inspect dres Continue plan of care for long term goal and reassess Rationale- Assessing the wound at intervals twice a day can provide information on how wound healing is proceeding. (Black & Hawks, 2009).
-Keep the wound moist.
Rationale- A moist environment promotes collagen synthesis,granulation tissue formation, and epithelial cell migration. (Black & Hawks, 2009).
-Apply Bactroban 1G topically to right foot and second digit twice a day.
Rationale- Bactroban treats infected skin by inhibiting bacterial protein synthesis. (Deglin & Vallerand, 2008).
-Provide nutritional support.
Rationale- A diet high in protein, and vitamins facilitates healing. (Black & Hawks, 2009).
-Teach the client how to inspect the wound.
Rationale- This can provide prompt treatment to the wound. C(arpenito-Moyet, 2010).
Nursing Diagnosis # 3
Evaluation
Ineffective health maintenance r/t lack of motivation and subst Goal not met. Pt. did not verbalize an intent to enga ge in health maintenance behaviors by discharge. C Supporting Data
ontinue plan of care and some revisions to the planof care are as follows: 1.) Teach pt. the benefits of exercise daily.
Rationale- benefits of exercise are decreased weigh t, lower blood pressure, improved mood, decreased -Pt. states “I know I am diabetic but I eat what I want. They d stress, and reduces chances of heart disease. (Black on’t feed you enough in here (hospital), you have to eat when you’re diabetic because your sugar will go down. I probably e 2.) Assist client and family to identify behaviors th at are detrimental to their health PRN.
- Oral hygiene poor as evidenced by missing teeth, halitosis, a Rationale- Providing information from themselves can foster a sense that change is possible. (Carpenit Short Term Goal
The patient will verbalize intent to engage in health maintenan 3.) Teach patient basics of a balanced nutritional in take according to his 1800 calorie ADA diet.
Rationale- This can help the patient understand his Long Term Goal
diabetic diet and give him a sense of control. (Blac The patient will quit smoking, and drinking alcohol in two mo Interventions
Evaluation
-Teach patient about harmful effects of alcohol use PRN.
Long term goal not met. Patient showed no interest Rationale- alcohol is associated with many problems includin in quitting smoking and drinking alcohol in two mo g hepatitis, cirrhosis, pancreatitis, liver cancers, and 50% of al nths. Continue plan of care and some revisions are l injuries. (Black & Hawks, 2009).
-Give patient community resources for alcohol addiction, and 1.) Assess pts. desire to stop smoking.
Rationale- Assessment of the desire to quit smokin Rationale- Community resources can provide education and s g is the first step to quitting. (Black & Hawks, 2009 upport to the abuser and the family. (Black & Hawks, 2009).
-Encourage smoking cessation and provide alternatives to smo 2.) Encourage pt. to stop smoking PRN.
king such as walking, cleaning the house, and building a supp Rationale- Quitting smoking now, decreases risks a ssociated with smoking.(Black & Hawks, 2009).
Rationale- Helping the patient to personalize a stop smoking p 3.) Call the physician for an order for Chantix.
lan can increase chances of quitting. (Black & Hawks, 2009).
Rationale- Chantix is a prescription drug to decreas -Promote proper nutrition through teaching and meal plans du e the desire to smoke by preventing the biding of ni cotine to receptors. (Deglin & Vallerand, 2008).
Rationale- the goal of dietary management for diabetes is impr 4.) Have the patients family talk to the patient abou oving metabolic control by making changes in nutrition habits t how substance abuse can affect them.
Rationale- substance abuse has a major impact on f -Encourage good oral hygiene through teaching PRN.
amily members. (Black & Hawks, 2009).
Rationale- Teaching that natural teeth are more functional tomasticate food for effective digestion, and the prevention of cavities and gum disease is important. (Black & Hawks, 2009).

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