Concept Map Color Coded 3 PDF

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midterm exam study guide with notes from the book and lecture ...

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Name: Caroline Gettelfinger

Top 3 System Priorities 1.Integumentary 2: respiratoy 3: cardiac

Pt. Initials: ZH Date: 2/03/2016

Nursing Diagnosis: Impaired Skin Integrity

Nursing Diagnosis: Ineffective peripheral tissue perfusion

Nursing Diagnosis:

Pertinent Data:  Bilateral chronic venous stasis  14.8 WBC, 187 glucose  Cellulitis in Lower right leg/ankle  Foul smelling, yellow/clear exudate  BMI 93  HTN  Pain reported as a 9 on a 0-10 scale

Pertinent Data:  BMI 93  Impaired mobility  Cellulitis in the lower right leg/ankle with yellow exudate  HTN, COPD  Dry, calloused skin on feet  Bilateral chronic venous stasis

Pertinent Data:

Measureable Goal*: Patient’s wounds will be kept clean and will remain free from further infection during my shift on 2/3/16

Measurable Goal *: Patient will demonstrate increased perfusion as appropriate (skin warm and dry, peripheral pulses, decrease in edema, free of pain) by end of shift.

Measurable Goal

Interventions/Rationale/Response*:  



Keep the area clean and dry using Silver dressings. Support the dressing with Kerlix gauze. Complete skin inspection when changing the dressing. Note the length, width, and depth, as well as the amount and type of exudate. Note the presence of compromised mobility that may impact client’s self-care and assist the client in understanding the importance of daily maintenance.



Goal Met Goal Partially Met Goal Not Met

Evaluation: Patient goal was met aeb no new infections.

Interventions/Rationale/Response*:  Administer anticoagulation medicines to improve tissue perfusion.  Encourage ambulation when possible as patient can tolerate.  Emphasize need for some form of regular exercise, a well-balanced diet, and cessation of smoking.

Goal Met Goal Partially Met Goal Not Met



Evaluation: Patient edema decreased by end of shift after ambulating around the room.

Interventions/Rationale/Response*:

Goal Met Goal Partially Met Goal Not Met Evaluation:

* See Attached

1 :Di ag nos i s :I mpa i r e ds ki ni nt e g r i t yr / ti mpa i r e sc i r c ul at i on/ s e ns a t i o na e br i g hta nkl ec e l l ul i t i s . Nur s i ngI nt e r v e nt i o ns( Mi ni mum o f3) Ra t i o na l e Pat i e ntRe s po ns e Ke e pt h ea r e ac l e a na n dd r yu s i n gS i l v e rd r e s s i n g s . De c r e a s ec h a n c eo fi n f e c t i o n Pa t i e n td i dn o tr e p or tp a i nwhi l ec h a n g i n gt h edr e s s i n g . Sup p o r tt h edr e s s i n gwi t hKe r l i xg a u z e . Compl e t es k i ni ns pe c t i o nwhe nc h a n g i n gt h ed r e s s K i n e g e . pu pt oda t er e c o r d so ft h ewou n dc ha r a c t e r i s t P i c a s t i e n ti su n a wa r eo fh e rwo u ndc h a r a c t e r i s t i c s . No t et h el e n gt h ,wi dt h , a n dde p t h , a swe l la st het yp e

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2:Di a gno s i s : Nur s i ngI nt e r v e nt i o ns( Mi ni mum of3 ) Ra t i ona l e Pa t i e ntRe s po ns e Ad mi n i s t e ra n t i c o a g ul a t i o nme d i c i n e st oi mp r o v e De c r e a s ec l o t t i n ga bi l i t y Pa t i e n tt o l e r a t e dLo v e n o xs u bqi n j e c t i o n. t i s s u ep e r f u s i on . En c ou r a g ea mb u l a t i o nwh e npo s s i b l ea sp a t i e ntc a nI n c r e a s ebl o odflo wt oe x t r e mi t i e sa n d P v a e t n i e o n u t s a mb u l a t e da r o un dr o o m wi t hs o med i ffic u l t y t o l e r a t e . r e t u r nt oh e a r t . h a nc ec i r c ul a t i o na n dp r omo t ewe l l b e i n g .Pa t i e n ti sa wa r et h a tl i f e s t y l ec h a n g e sn e e dt ob ema d e n Emphasize need for some form of regular exercise, En a well-balanced diet, and cessation of smoking.

3:Di a gno s i s : Nur s i ngI nt e r v e nt i o ns( Mi ni mum of3 )

Ra t i ona l e

Pa t i e ntRe s po ns e

Lab Interventions

Rationale

Patient Response...