Mrs ????? is a 56-year-old client withdiabetes, hypertension and asthma. Her current weight is 300 lbs. You are thenurse who is caring for Mrs.????. during this hospital stay for a gaping legwound following a fall at home.
Currently, Mrs. ?????. is alert and oriented. Shecan get up to the bathroom with a walker and the assistance of one person tohelp her stand. Many times, Mrs. ????? states she dribbles urine. She spends mostof her time sitting in a chair or in bed.
Mrs. ??????. is currently ordered a 1500calorie ADAdiet. She has only been eating about 50% of the food on her try. She says shedoesn't like hospital food. Mrs. ??????. is on insulin and oral hypoglycemic agents.Her blood sugars continue to be high. Since her blood sugar has beenuncontrolled for a long time, she has some peripheral neuropathy in both of herfeet. Because of her asthma, she is currently taking oral Prednisone and is onthe steroid inhaler Azmacort.
Mrs. ?????'s wound requires a dressingchange b.i.d. The wound extends into the subcutaneous fat and appears large andgaping with a moderate amount of pinkish-red drainage. It is clean and healingwith new connective granulation tissue forming.
Ok Nurses what is not only the correct nursing Diagnosis for this but also the shortest.
I did this for class and there was just so much stuff to add in there and I cannot do it without writing a lot and we are being told that "everything needs to be short and to the point blah blah...."
I am having a hard time keeping it short, anybody have suggestions??
Here is what I put in homework and am wondering how to shorten with out leaving out to much.
Patien tmay have a potential to develop activity intolerance AEB liking to sit in her chair most of time, diabetes, leg wound, asthma Dx, and assistance needed to stand
Patient has potential for Impaired Skin integrity AEB low activity, incontinence of urine which could lead to moisture breakdown (maceration), excessive weight,peripheral neuropathy in feet r/t,medications, diabetes, and poor nutritional intake .
Patient has potential for infection AEB leg wound, poor nutritional intake, diabetes,hypertension, and asthma which are chronic diseases, which may weaken her immune system.
Patient has potential to develop disturbed body image AEB social isolation, poor food intake, obesity, and open wound
Last edit by pwiser69 on Sep 9, '12
: Reason: improper formatting